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1487066320 NPI number — MATTHEW JOHANSEN MS, LCPC, QSUDP

NPI Number: 1487066320
Health Care Provider/Practitioner: MATTHEW JOHANSEN MS, LCPC, QSUDP

Information about “1487066320” NPI (MATTHEW JOHANSEN MS, LCPC, QSUDP) exists in 1487066320 in HTML format HTML  |  1487066320 in plain Text format TXT  |  1487066320 in PDF (Portable Document Format) PDF  |  1487066320 in an XML format XML  formats.

NPI Number : 1487066320 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1487066320",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "JOHANSEN",
    "FirstName": "MATTHEW",
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "MS, LCPC, QSUDP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "6407 W ROBERTSON DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BOISE",
    "MailingAddressStateName": "ID",
    "MailingAddressPostalCode": "83709-2176",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "208-836-8247",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "2131 S BONITO WAY",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "MERIDIAN",
    "PracticeLocationAddressStateName": "ID",
    "PracticeLocationAddressPostalCode": "83642-1659",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "208-202-4729",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "05/27/2014",
    "LastUpdateDate": "02/22/2019",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "101YM0800X",
        "TaxonomyName": "Mental Health Counselor",
        "LicenseNumber": "LCPC-6475",
        "LicenseNumberStateCode": "ID",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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