Healthcare Provider Details

I. General information

NPI: 1437409414
Provider Name (Legal Business Name): MARLENA LAURA-JOANN JOHNSON QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLENA LAURA-JOANN JOHNSON QMHP

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 VILLA RD
NEWBERG OR
97132-1856
US

IV. Provider business mailing address

901 BRUTSCHER ST STE D PMB 150
NEWBERG OR
97132-6096
US

V. Phone/Fax

Practice location:
  • Phone: 503-431-0063
  • Fax: 503-554-1848
Mailing address:
  • Phone: 503-431-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number094265
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: