Provider Demographics
NPI:1104420462
Name:JOHNSON, SANDRA LYNN (LPC LLC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 W RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-9049
Mailing Address - Country:US
Mailing Address - Phone:970-880-2599
Mailing Address - Fax:
Practice Address - Street 1:631 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:MANCOS
Practice Address - State:CO
Practice Address - Zip Code:81328-9049
Practice Address - Country:US
Practice Address - Phone:970-880-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3424101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty