Provider Demographics
NPI:1235258237
Name:JOHNSON, ELLEN MAXINE (MS)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:MAXINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:MAXINE
Other - Last Name:HICKMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5083 TAYLOR AVE NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-3188
Mailing Address - Country:US
Mailing Address - Phone:206-842-0664
Mailing Address - Fax:206-842-0664
Practice Address - Street 1:5083 TAYLOR AVE NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-3188
Practice Address - Country:US
Practice Address - Phone:206-842-0664
Practice Address - Fax:206-842-0664
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006614101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health