Provider Demographics
NPI:1457991358
Name:JOHNSON, TRACI
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYNN
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5607 W 75TH TER
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-4517
Mailing Address - Country:US
Mailing Address - Phone:913-957-0623
Mailing Address - Fax:
Practice Address - Street 1:5607 W 75TH TER
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-4517
Practice Address - Country:US
Practice Address - Phone:913-957-0623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9167156576101YS0200X
KS7918104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool