1962558429 NPI number — MARIAN TAN JOHNSON MA, LPC, NCC, RPT-S

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962558429 NPI number — MARIAN TAN JOHNSON MA, LPC, NCC, RPT-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARIAN
Provider Middle Name:
TAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC, NCC, RPT-S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAN
Provider Other First Name:
MARIAN
Provider Other Middle Name:
UY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1962558429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2332
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28607-2332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-406-5584
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
895 STATE FARM RD
Provider Second Line Business Practice Location Address:
SUITE 504
Provider Business Practice Location Address City Name:
BOONE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28607-4917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-406-5584
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1475 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 6514 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6103874 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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