Provider Demographics
NPI:1215127279
Name:JOHNSON, DOREEN DIANE
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5193 W MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-8181
Mailing Address - Country:US
Mailing Address - Phone:815-973-0552
Mailing Address - Fax:
Practice Address - Street 1:2611 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-4151
Practice Address - Country:US
Practice Address - Phone:815-625-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor