Provider Demographics
NPI:1457192965
Name:JOHNSON, LACI (MSED)
Entity type:Individual
Prefix:
First Name:LACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7323 THOROUGHBRED DR APT 3D
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2350
Mailing Address - Country:US
Mailing Address - Phone:260-271-9081
Mailing Address - Fax:
Practice Address - Street 1:8113 LIMA RD STE B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-2162
Practice Address - Country:US
Practice Address - Phone:260-267-5175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99125292A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health