Provider Demographics
NPI:1326198243
Name:JOHNSON, BETTY LOUANN (MA)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:LOUANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KITTY
Other - Middle Name:
Other - Last Name:ASWEGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68848-1328
Mailing Address - Country:US
Mailing Address - Phone:308-440-8054
Mailing Address - Fax:308-234-6604
Practice Address - Street 1:2210 30TH AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-9687
Practice Address - Country:US
Practice Address - Phone:308-440-8054
Practice Address - Fax:308-234-6604
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NELADC 305101YA0400X
NELMHP 294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE713406000Medicaid
NE10025064900Medicaid
NE10025131100Medicaid
NE10025131000Medicaid
NE84769OtherBLUE CROSS PROVIDER NUMBE