Provider Demographics
NPI:1851484414
Name:JOHNSON, ELYBIA WILSON
Entity type:Individual
Prefix:MS
First Name:ELYBIA
Middle Name:WILSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MCP, LPC, LMFT
Mailing Address - Street 1:1991 LAKELAND DRIVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-613-6417
Mailing Address - Fax:601-981-0910
Practice Address - Street 1:1991 LAKELAND DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-613-6417
Practice Address - Fax:601-981-0910
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0430101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health