Provider Demographics
NPI:1265697197
Name:JOHNSON, MARY CAROL (QMHA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CAROL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:CAROL
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1840 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3422
Mailing Address - Country:US
Mailing Address - Phone:541-756-2057
Mailing Address - Fax:541-751-7905
Practice Address - Street 1:1840 UNION AVE
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-3422
Practice Address - Country:US
Practice Address - Phone:541-756-2057
Practice Address - Fax:541-751-7905
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator