Provider Demographics
NPI:1952613267
Name:JOHNSON, KATHERINE MARIE (ICRC/AODA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ICRC/AODA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 S 500 W
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-2029
Mailing Address - Country:US
Mailing Address - Phone:801-473-8492
Mailing Address - Fax:
Practice Address - Street 1:185 E 400 N
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1563
Practice Address - Country:US
Practice Address - Phone:801-669-8032
Practice Address - Fax:801-850-9354
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7229222-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)