Provider Demographics
NPI:1821723651
Name:JOHANSON, KATHERINE (PHD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:JOHANSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 E 3360 S APT 46
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4539
Mailing Address - Country:US
Mailing Address - Phone:701-527-7612
Mailing Address - Fax:
Practice Address - Street 1:1700 WHEELING ST # A-211M
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-7211
Practice Address - Country:US
Practice Address - Phone:701-527-7612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12460824-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical