Provider Demographics
NPI:1568098713
Name:JOHNSON, BRANDON CORY (MA, LMFT, LMHC, LPC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:CORY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, LMFT, LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8514 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1140
Mailing Address - Country:US
Mailing Address - Phone:971-231-0768
Mailing Address - Fax:971-200-5813
Practice Address - Street 1:8514 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-1140
Practice Address - Country:US
Practice Address - Phone:971-231-0768
Practice Address - Fax:971-200-5813
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61514431101YM0800X
AK215581101YP2500X
ORT2389106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500814559Medicaid