Provider Demographics
NPI:1164092003
Name:JOHNSON, COLEEN ELIZABETH (MSW, LSWAIC)
Entity Type:Individual
Prefix:
First Name:COLEEN
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW, LSWAIC
Other - Prefix:
Other - First Name:COLEEN
Other - Middle Name:E
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:747 WESTPOINT CT
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-2695
Mailing Address - Country:US
Mailing Address - Phone:360-846-7309
Mailing Address - Fax:
Practice Address - Street 1:1010 E COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5624
Practice Address - Country:US
Practice Address - Phone:360-542-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC61166287101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker