Provider Demographics
NPI:1982041430
Name:JOHNSON, PATTI JEAN (LPC,NCC)
Entity Type:Individual
Prefix:MRS
First Name:PATTI
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC,NCC
Other - Prefix:MISS
Other - First Name:PATTI
Other - Middle Name:JEAN
Other - Last Name:GISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:750 W USTICK RD STE 120
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6133
Mailing Address - Country:US
Mailing Address - Phone:208-366-1607
Mailing Address - Fax:208-366-1602
Practice Address - Street 1:251 W ARROWROCK LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4802
Practice Address - Country:US
Practice Address - Phone:208-366-1607
Practice Address - Fax:208-366-1602
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5253101YP2500X
IDLCPC6122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional