Provider Demographics
NPI:1962067009
Name:JOHNSON, TINA MARIE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:JOHNSON
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 1:11611 NE ANGELO DR APT 35
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4317
Mailing Address - Country:US
Mailing Address - Phone:360-485-2889
Mailing Address - Fax:
Practice Address - Street 1:13500 SE 7TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-6909
Practice Address - Country:US
Practice Address - Phone:360-699-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor