Provider Demographics
NPI:1093483745
Name:JOHNSON, KORIE AUTUMN
Entity Type:Individual
Prefix:
First Name:KORIE
Middle Name:AUTUMN
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 1:3494 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4607
Mailing Address - Country:US
Mailing Address - Phone:971-304-0660
Mailing Address - Fax:
Practice Address - Street 1:3494 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4607
Practice Address - Country:US
Practice Address - Phone:971-304-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst