Provider Demographics
NPI:1750868642
Name:JOHNSON, MARIE KATHLEEN (BCBA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:KATHLEEN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 NEW ST APT 108
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1779
Mailing Address - Country:US
Mailing Address - Phone:262-880-5581
Mailing Address - Fax:
Practice Address - Street 1:10450 72ND AVE
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2911
Practice Address - Country:US
Practice Address - Phone:645-326-2657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI242-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst