Provider Demographics
NPI:1811379480
Name:JOHNSON, KA RIN KAY (LCSW)
Entity Type:Individual
Prefix:
First Name:KA RIN
Middle Name:KAY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KA RIN
Other - Middle Name:KAY
Other - Last Name:MENTZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:161 HIGH ST SE STE 204
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3610
Mailing Address - Country:US
Mailing Address - Phone:503-749-0306
Mailing Address - Fax:503-749-0343
Practice Address - Street 1:161 HIGH ST SE STE 204
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3610
Practice Address - Country:US
Practice Address - Phone:503-749-0306
Practice Address - Fax:503-749-0343
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL79071041C0700X, 101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500688153Medicaid