Healthcare Provider Details

I. General information

NPI: 1144431974
Provider Name (Legal Business Name): LISA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 NE HWY 20 CHILDREN'S FARM HOME
CORVALLIS OR
97330
US

IV. Provider business mailing address

740 ARCADIA DR
EUGENE OR
97401-5317
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-5975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number9503141
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: