Provider Demographics
NPI:1356691869
Name:JOHNSON, CAROL LOUISE (MTE)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:LOUISE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MTE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-6600
Mailing Address - Country:US
Mailing Address - Phone:541-567-2536
Mailing Address - Fax:
Practice Address - Street 1:331 SOUTHEAST 2ND STREET
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97838
Practice Address - Country:US
Practice Address - Phone:541-276-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR931215381104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker