Provider Demographics
NPI:1487020608
Name:JOHNSON, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:MORTIMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2440 WILLAMETTE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-3170
Mailing Address - Country:US
Mailing Address - Phone:541-321-2278
Mailing Address - Fax:541-246-8826
Practice Address - Street 1:2440 WILLAMETTE ST STE 201
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3170
Practice Address - Country:US
Practice Address - Phone:541-321-2278
Practice Address - Fax:541-246-8826
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC6468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health