Provider Demographics
NPI:1588544548
Name:JOHNSON, STACEY LEBOUEF (PPS)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LEBOUEF
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 HIGHWAY 90 W
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-7649
Mailing Address - Country:US
Mailing Address - Phone:757-653-2692
Mailing Address - Fax:
Practice Address - Street 1:7106 HIGHWAY 90 W
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-7649
Practice Address - Country:US
Practice Address - Phone:757-653-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0014103TS0200X
GA1997934103TS0200X
TN000758250103TS0200X
UT820792103TS0200X
OK0972986103TS0200X
VAPPS-0609322103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool