Provider Demographics
NPI:1720512577
Name:JOHANSEN, PENNY
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:JOHANSEN
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 1:5436 232ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-6220
Mailing Address - Country:US
Mailing Address - Phone:206-380-3009
Mailing Address - Fax:
Practice Address - Street 1:5436 232ND AVE SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029
Practice Address - Country:US
Practice Address - Phone:206-380-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACAAR.CG.60542450106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACAAR.CG.60542450OtherWA STATE LICENSE