Provider Demographics
NPI:1629170410
Name:JOHNSON, DIANE WILSON (LCMHC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:WILSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCMHC
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 1114
Mailing Address - Street 2:30 PLEASANT ST
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-1114
Mailing Address - Country:US
Mailing Address - Phone:603-447-2239
Mailing Address - Fax:603-447-2239
Practice Address - Street 1:30 PLEASANT STREET
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-1114
Practice Address - Country:US
Practice Address - Phone:603-447-2239
Practice Address - Fax:603-447-2239
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH90101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009004Medicaid