Provider Demographics
NPI:1306517420
Name:JOHNSTON, SECRET ANN (CADC I/CRM/PSS/QMHAR)
Entity type:Individual
Prefix:
First Name:SECRET
Middle Name:ANN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:CADC I/CRM/PSS/QMHAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:1631 SW COUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-CRM-891101YA0400X
OR23-QMHA-R-3855101YM0800X
ORTHW000106531175T00000X
OR23-01-10621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500813291Medicaid