Provider Demographics
NPI:1417241936
Name:JOHANSON, KRISTEN ANN (LCMHC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ANN
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70B N PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-3300
Mailing Address - Country:US
Mailing Address - Phone:802-324-8318
Mailing Address - Fax:
Practice Address - Street 1:364 DORSET ST STE 212
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6272
Practice Address - Country:US
Practice Address - Phone:802-658-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000713101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health