Provider Demographics
NPI:1962558429
Name:JOHNSON, MARIAN TAN (MA, LPC, NCC, RPT-S)
Entity type:Individual
Prefix:
First Name:MARIAN
Middle Name:TAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, LPC, NCC, RPT-S
Other - Prefix:
Other - First Name:MARIAN
Other - Middle Name:UY
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2332
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-2332
Mailing Address - Country:US
Mailing Address - Phone:828-406-5584
Mailing Address - Fax:
Practice Address - Street 1:895 STATE FARM RD
Practice Address - Street 2:SUITE 504
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4917
Practice Address - Country:US
Practice Address - Phone:828-406-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1475101YP2500X
NC6514101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103874Medicaid