Provider Demographics
NPI:1790383537
Name:JOHNSON, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 BARNES CT SW APT 307
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-1469
Mailing Address - Country:US
Mailing Address - Phone:360-972-6181
Mailing Address - Fax:
Practice Address - Street 1:320 6TH ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2503
Practice Address - Country:US
Practice Address - Phone:360-280-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61483411103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst