Provider Demographics
NPI:1902942600
Name:JOHNSON, LISA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9850 W ST LUKES DR STE 320
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7912
Practice Address - Country:US
Practice Address - Phone:208-505-2222
Practice Address - Fax:208-205-7666
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3122101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCPC3122OtherLICENSE