Healthcare Provider Details

I. General information

NPI: 1487020608
Provider Name (Legal Business Name): HEATHER JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER MORTIMORE M.A.

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 WILLAMETTE ST STE 201
EUGENE OR
97405-3170
US

IV. Provider business mailing address

2440 WILLAMETTE ST STE 201
EUGENE OR
97405-3170
US

V. Phone/Fax

Practice location:
  • Phone: 541-321-2278
  • Fax: 541-246-8826
Mailing address:
  • Phone: 541-321-2278
  • Fax: 541-246-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC6468
License Number StateOR

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: