Provider Demographics
NPI:1720592298
Name:JOHANNSEN, ELLEN STORM (MS)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:STORM
Last Name:JOHANNSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:JANE
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6121 INDIAN SCHOOL RD NE STE 141
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3176
Mailing Address - Country:US
Mailing Address - Phone:505-888-1362
Mailing Address - Fax:
Practice Address - Street 1:6121 INDIAN SCHOOL RD NE STE 141
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3176
Practice Address - Country:US
Practice Address - Phone:505-888-1362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0192981103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling