Provider Demographics
NPI:1104502244
Name:JOHNSON, NICHOLAS DANE (LMNFTA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DANE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMNFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 FACTORIA BLVD SE STE 405
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-5259
Mailing Address - Country:US
Mailing Address - Phone:425-590-9419
Mailing Address - Fax:
Practice Address - Street 1:4122 FACTORIA BLVD SE STE 405
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-5259
Practice Address - Country:US
Practice Address - Phone:422-559-0941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61628944106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist