Healthcare Provider Details

I. General information

NPI: 1164092003
Provider Name (Legal Business Name): COLEEN ELIZABETH JOHNSON MSW, LICSW, CMHS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COLEEN ELIZABETH PAYNE

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/30/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2203 OLD HIGHWAY 99 S RD
MOUNT VERNON WA
98273-9009
US

IV. Provider business mailing address

747 WESTPOINT CT
BURLINGTON WA
98233-2695
US

V. Phone/Fax

Practice location:
  • Phone: 360-542-8810
  • Fax: 360-542-8811
Mailing address:
  • Phone: 360-846-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSC61166287
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSC61166287
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61166287
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLW61501471
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: