Provider Demographics
NPI:1598823775
Name:JOHNSON, SUSAN A (PHD, MED LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, MED LMHC, NCC
Other - Prefix:
Other - First Name:SUZIE
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC
Mailing Address - Street 1:107 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1510
Mailing Address - Country:US
Mailing Address - Phone:509-838-4651
Mailing Address - Fax:509-363-2762
Practice Address - Street 1:107 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:509-363-2762
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00006906101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1598823775Medicaid