Provider Demographics
NPI:1275197139
Name:JOHNSON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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:W151N8649 MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3108
Mailing Address - Country:US
Mailing Address - Phone:262-364-8720
Mailing Address - Fax:
Practice Address - Street 1:1205 S 70TH ST
Practice Address - Street 2:STE 301
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214
Practice Address - Country:US
Practice Address - Phone:414-475-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI611-228106H00000X
WI1456106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist