Provider Demographics
NPI:1114208980
Name:JOHNSON, MARILEE (MRC, LPC)
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 WASHINGTON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1600
Mailing Address - Country:US
Mailing Address - Phone:208-847-4464
Mailing Address - Fax:208-847-4251
Practice Address - Street 1:455 WASHINGTON ST STE 2
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1600
Practice Address - Country:US
Practice Address - Phone:208-847-4464
Practice Address - Fax:208-847-4251
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5414101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805405600Medicaid