Provider Demographics
NPI:1154813558
Name:JOHNSON, PORSCHE T
Entity Type:Individual
Prefix:
First Name:PORSCHE
Middle Name:T
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 1:2649 N 73RD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85035-3253
Mailing Address - Country:US
Mailing Address - Phone:602-314-0120
Mailing Address - Fax:
Practice Address - Street 1:17505 N 79TH AVE STE 410
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8732
Practice Address - Country:US
Practice Address - Phone:623-800-7980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16824101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor