Provider Demographics
NPI:1588936199
Name:JOHNSON, PEGGY M (LPC-C)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 702504
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-2504
Mailing Address - Country:US
Mailing Address - Phone:918-791-0026
Mailing Address - Fax:918-791-0043
Practice Address - Street 1:4122 W 55TH PL STE 119
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-9108
Practice Address - Country:US
Practice Address - Phone:918-791-0026
Practice Address - Fax:918-791-0043
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid