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General NPI Number Information
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NPI Number | 1235783366
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Entity Type | Individual
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Provider Name | STAR MARIE JOHNSON SUDP
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Gender | Female
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Dates
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Enumeration Date | 07/26/2019
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Last Update Date | 09/09/2025
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Provider Practice Location Address
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Address Line | 1812 SUMNER AVE
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City | ABERDEEN
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State | WA
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Zip | 98520-4602
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Country | US
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Telephone | 360-584-5078
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Fax | 844-554-3370
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Provider Business Mailing Address
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Address Line | 380 W HAVEN DR
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City | ELMA
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State | WA
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Zip | 98541-9515
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Country | US
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Telephone | 360-270-3000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | CG60987591
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | CO61000223
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CP61505739
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License Number State | WA
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