Basic Information
| Provider Information | |||||||||
| NPI: | 1699980672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | PAULINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CMA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MINOR | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | PAULINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1907 J ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974774285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415058166 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1790 W 11TH AVE | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416861262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.