Provider Demographics
NPI:1255024030
Name:JOHNSON, BRENNA (PPC)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1928 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-7305
Mailing Address - Country:US
Mailing Address - Phone:907-529-1891
Mailing Address - Fax:
Practice Address - Street 1:1928 COTTONWOOD DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-7305
Practice Address - Country:US
Practice Address - Phone:907-529-1891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1384101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor