Provider Demographics
NPI:1306353123
Name:JOHANSSON, PERSEPHONE
Entity type:Individual
Prefix:
First Name:PERSEPHONE
Middle Name:
Last Name:JOHANSSON
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 1:35416 25TH AVE SW APT 7-201
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-3343
Mailing Address - Country:US
Mailing Address - Phone:860-578-6287
Mailing Address - Fax:
Practice Address - Street 1:615 W TITUS ST STE 103
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5749
Practice Address - Country:US
Practice Address - Phone:860-578-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60736722101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health