=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114208980
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILEE JOHNSON MRC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 03/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 WASHINGTON ST STE 2
-----------------------------------------------------
City | MONTPELIER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83254-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-847-4464
-----------------------------------------------------
Fax | 208-847-4251
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 WASHINGTON ST STE 2
-----------------------------------------------------
City | MONTPELIER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83254-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-847-4464
-----------------------------------------------------
Fax | 208-847-4251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-5414
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------