Provider Demographics
NPI:1669333639
Name:JOHNSON, AUTRY
Entity type:Individual
Prefix:
First Name:AUTRY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22593
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2593
Mailing Address - Country:US
Mailing Address - Phone:971-266-3715
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 22593
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97269-2593
Practice Address - Country:US
Practice Address - Phone:971-266-3715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-19
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health