Provider Demographics
NPI:1316077860
Name:JOHNSON, EMILY ROTH (LPC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ROTH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:LEIGH
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0588
Mailing Address - Country:US
Mailing Address - Phone:920-294-4070
Mailing Address - Fax:920-294-4139
Practice Address - Street 1:500 LAKE STEEL STREET
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-4070
Practice Address - Fax:920-294-4139
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3349125101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40994500Medicaid