Provider Demographics
NPI:1063635852
Name:JOHNSON, PAMELA K (LCPC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
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 781
Mailing Address - Street 2:
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425-0781
Mailing Address - Country:US
Mailing Address - Phone:406-278-7470
Mailing Address - Fax:406-278-5899
Practice Address - Street 1:310 S MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425-2336
Practice Address - Country:US
Practice Address - Phone:406-278-7470
Practice Address - Fax:406-278-5899
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLCPC-582101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT255047Medicaid
MT74746OtherBLUECROSSBLUESHIELD