Provider Demographics
NPI:1255546768
Name:JOHNSON, DIANE ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ELIZABETH
Last Name:JOHNSON
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:P.O. BOX 37
Mailing Address - Street 2:
Mailing Address - City:PORT HADLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98339
Mailing Address - Country:US
Mailing Address - Phone:360-379-8821
Mailing Address - Fax:360-379-8821
Practice Address - Street 1:219 W PATISON ST
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9710
Practice Address - Country:US
Practice Address - Phone:360-379-8821
Practice Address - Fax:360-379-8821
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001854103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7110810Medicaid
WAAB03458Medicare ID - Type Unspecified