Healthcare Provider Details

I. General information

NPI: 1356691869
Provider Name (Legal Business Name): CAROL LOUISE JOHNSON MTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 SOUTHEAST 2ND STREET
PENDLETON OR
97838
US

IV. Provider business mailing address

595 NW 11TH ST
HERMISTON OR
97838-6600
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-6207
  • Fax:
Mailing address:
  • Phone: 541-567-2536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number931215381
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: