1821289034 NPI number — STACEY SHUMWAY JOHNSON LPCC-S, LICDC-CS

Table of content: STACEY SHUMWAY JOHNSON LPCC-S, LICDC-CS (NPI 1821289034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821289034 NPI number — STACEY SHUMWAY JOHNSON LPCC-S, LICDC-CS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUMWAY JOHNSON
Provider First Name:
STACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPCC-S, LICDC-CS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHUMWAY
Provider Other First Name:
STACEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPCC-S, LICDC-CS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821289034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 WASHINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45662-3914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-505-4500
Provider Business Mailing Address Fax Number:
740-353-8889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662-3914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-505-4500
Provider Business Practice Location Address Fax Number:
740-353-8889
Provider Enumeration Date:
08/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  104053 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: E.0600469-SUPV , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11816332 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000530777 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100283540 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".