Provider Demographics
NPI:1467810028
Name:JOHNSON, LAURA (MS, SAC-IT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9532 E. 16 FRONTAGE RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-6742
Mailing Address - Country:US
Mailing Address - Phone:608-783-0506
Mailing Address - Fax:608-783-0242
Practice Address - Street 1:9532 E. 16 FRONTAGE RD
Practice Address - Street 2:STE. 100
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-6742
Practice Address - Country:US
Practice Address - Phone:608-783-0506
Practice Address - Fax:608-783-0242
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17497-130101YA0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1003150004Medicaid