Provider Demographics
NPI:1114951159
Name:JOHANSSON, PERNILLA L (LCSW)
Entity Type:Individual
Prefix:
First Name:PERNILLA
Middle Name:L
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5460 BROWNINGS CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-8849
Mailing Address - Country:US
Mailing Address - Phone:541-305-5804
Mailing Address - Fax:
Practice Address - Street 1:5460 BROWNINGS CORNERS RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8849
Practice Address - Country:US
Practice Address - Phone:541-305-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR30601041C0700X
ORL30601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292270Medicaid
ORL3060OtherSTATE LICENSE
ORS90339Medicare UPIN
ORR105258Medicare PIN