=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962558429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAN TAN JOHNSON MA, LPC, NCC, RPT-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 09/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 895 STATE FARM RD SUITE 504
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28607-4917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-406-5584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2332
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28607-2332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-406-5584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 1475
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6514
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------