Provider Demographics
NPI:1093404402
Name:JOHNSON, SARA EILEEN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:EILEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W MARCY AVE
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-3419
Mailing Address - Country:US
Mailing Address - Phone:253-381-7207
Mailing Address - Fax:
Practice Address - Street 1:633 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4700
Practice Address - Country:US
Practice Address - Phone:800-781-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61375693106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician