Provider Demographics
NPI:1912917352
Name:JOHANNES, AMY S (CSAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:JOHANNES
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8031
Mailing Address - Country:US
Mailing Address - Phone:920-539-9427
Mailing Address - Fax:920-926-8885
Practice Address - Street 1:1044 S PARK AVE
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-8031
Practice Address - Country:US
Practice Address - Phone:920-539-9427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2137101Y00000X, 101YA0400X
IL38635101YA0400X
OH162616101YA0400X
VA4127101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor