Provider Demographics
NPI:1295545515
Name:JOHNSON, MARISOL (CO 61614092)
Entity type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CO 61614092
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N RIVARD RD
Mailing Address - Street 2:
Mailing Address - City:MOXEE
Mailing Address - State:WA
Mailing Address - Zip Code:98936-9809
Mailing Address - Country:US
Mailing Address - Phone:509-902-2521
Mailing Address - Fax:
Practice Address - Street 1:33 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3414
Practice Address - Country:US
Practice Address - Phone:509-864-1418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61614092101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)