Provider Demographics
NPI:1780077610
Name:JOHANNESEN, AMY EDWARDSON (MA, LPC, LMHC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:EDWARDSON
Last Name:JOHANNESEN
Suffix:
Gender:F
Credentials:MA, LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 MAIN ST
Mailing Address - Street 2:STE. 444
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1803
Mailing Address - Country:US
Mailing Address - Phone:208-750-3000
Mailing Address - Fax:208-750-1244
Practice Address - Street 1:504 MAIN ST
Practice Address - Street 2:STE. 444
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1803
Practice Address - Country:US
Practice Address - Phone:208-750-3000
Practice Address - Fax:208-750-1244
Is Sole Proprietor?:No
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005257101YM0800X
IDLPC-5580101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health