Provider Demographics
NPI:1568655637
Name:JOHNSON, DEIDRA MCGIE (LCP)
Entity type:Individual
Prefix:MRS
First Name:DEIDRA
Middle Name:MCGIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:MISS
Other - First Name:DEIDRA
Other - Middle Name:LOUISE
Other - Last Name:MCGIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMLP
Mailing Address - Street 1:1102 S. ROUSE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762
Mailing Address - Country:US
Mailing Address - Phone:620-231-5310
Mailing Address - Fax:620-231-9893
Practice Address - Street 1:1102 S. ROUSE
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762
Practice Address - Country:US
Practice Address - Phone:620-231-5310
Practice Address - Fax:620-231-9893
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCP - 269103TC2200X, 103TF0000X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily