Provider Demographics
NPI:1881180164
Name:JOHNSON, PATRICIA MARIE (LPC)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:M
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4477 W EMERALD ST STE C100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2058
Mailing Address - Country:US
Mailing Address - Phone:208-321-0160
Mailing Address - Fax:208-321-0221
Practice Address - Street 1:4477 W EMERALD ST STE C100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2058
Practice Address - Country:US
Practice Address - Phone:208-321-0160
Practice Address - Fax:208-321-0221
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional