Provider Demographics
NPI:1235590258
Name:JOHNSON, ALYSA HARLESS (LCSW)
Entity Type:Individual
Prefix:
First Name:ALYSA
Middle Name:HARLESS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:ALYSA
Other - Middle Name:
Other - Last Name:HARLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11354 PLEASANT VALLEY RD # 94
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9000
Mailing Address - Country:US
Mailing Address - Phone:906-407-0047
Mailing Address - Fax:
Practice Address - Street 1:14011 LODGEPOLE CT
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9128
Practice Address - Country:US
Practice Address - Phone:906-407-0047
Practice Address - Fax:916-405-4002
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA774841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical