Healthcare Provider Details

I. General information

NPI: 1518318930
Provider Name (Legal Business Name): KATHY JOHANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 26TH ST
OGDEN UT
84401-2465
US

IV. Provider business mailing address

330 E 3325 N
NORTH OGDEN UT
84414-1538
US

V. Phone/Fax

Practice location:
  • Phone: 801-643-4817
  • Fax:
Mailing address:
  • Phone: 801-643-4817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: