Provider Demographics
NPI:1417296294
Name:JOHNSON, LISA CARLE (COUNSELOR)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:CARLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65653
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98464-1653
Mailing Address - Country:US
Mailing Address - Phone:253-396-5000
Mailing Address - Fax:
Practice Address - Street 1:1305 TACOMA AVE S STE 305
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1903
Practice Address - Country:US
Practice Address - Phone:253-396-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60248031101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health