Provider Demographics
NPI:1346758042
Name:JOHNSON, HEATHER MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8382 N WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-6028
Mailing Address - Country:US
Mailing Address - Phone:208-719-9110
Mailing Address - Fax:208-209-6026
Practice Address - Street 1:8382 N WAYNE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6028
Practice Address - Country:US
Practice Address - Phone:208-719-9110
Practice Address - Fax:208-209-6026
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40713101YM0800X
IDLMSW36887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health