Healthcare Provider Details

I. General information

NPI: 1285019133
Provider Name (Legal Business Name): LYN KAROL JOHNSON M.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 IRIS AVE
BOULDER CO
80304-2226
US

IV. Provider business mailing address

26246 REDLANDS BLVD APT 87
REDLANDS CA
92373-7748
US

V. Phone/Fax

Practice location:
  • Phone: 303-443-8500
  • Fax: 719-538-1433
Mailing address:
  • Phone: 909-747-8962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: