Provider Demographics
NPI:1801215520
Name:JOHANSON, TANYA M (LCPC)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5025
Mailing Address - Country:US
Mailing Address - Phone:207-783-9141
Mailing Address - Fax:207-783-4660
Practice Address - Street 1:1155 LISBON ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5025
Practice Address - Country:US
Practice Address - Phone:207-783-9141
Practice Address - Fax:207-783-4660
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC5423101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional