Provider Demographics
NPI:1982744553
Name:JOHNSON, MARY ELLEN (MA)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4457
Mailing Address - Country:US
Mailing Address - Phone:253-840-9743
Mailing Address - Fax:253-840-9743
Practice Address - Street 1:204 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5880
Practice Address - Country:US
Practice Address - Phone:253-840-9743
Practice Address - Fax:253-840-9743
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004806101YM0800X
WALF00001529106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist