Healthcare Provider Details

I. General information

NPI: 1235783366
Provider Name (Legal Business Name): STAR MARIE JOHNSON SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 SUMNER AVE
ABERDEEN WA
98520-4602
US

IV. Provider business mailing address

380 W HAVEN DR
ELMA WA
98541-9515
US

V. Phone/Fax

Practice location:
  • Phone: 360-584-5078
  • Fax: 844-554-3370
Mailing address:
  • Phone: 360-270-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCO61000223
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61505739
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCG60987591
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: