Provider Demographics
NPI:1356468045
Name:JOHNSON, THOMAS K (LPC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:K
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:971-386-2278
Mailing Address - Fax:503-224-4494
Practice Address - Street 1:1631 SW COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-6025
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3461101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500648624Medicaid