Provider Demographics
NPI:1881764355
Name:JOHNSON, COURTNEY E (PHD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 MARVIN RD NE STE C313
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-3878
Mailing Address - Country:US
Mailing Address - Phone:316-337-5432
Mailing Address - Fax:316-337-5481
Practice Address - Street 1:5137 BLACKTAIL CT NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-2136
Practice Address - Country:US
Practice Address - Phone:316-337-5432
Practice Address - Fax:316-337-5481
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP1011103TC0700X, 103T00000X
WA61442566103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS119691Medicare ID - Type Unspecified