Healthcare Provider Details

I. General information

NPI: 1962967232
Provider Name (Legal Business Name): DONNELL MARIE JOHANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 N 400 W
EPHRAIM UT
84627-5549
US

IV. Provider business mailing address

125 S STATE ST
MT PLEASANT UT
84647-1563
US

V. Phone/Fax

Practice location:
  • Phone: 435-283-8400
  • Fax: 435-283-8401
Mailing address:
  • Phone: 435-283-8400
  • Fax: 435-283-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateUT

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: