Provider Demographics
NPI:1235783366
Name:JOHNSON, STAR MARIE (SUDP)
Entity type:Individual
Prefix:
First Name:STAR
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 W HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9515
Mailing Address - Country:US
Mailing Address - Phone:360-270-3000
Mailing Address - Fax:
Practice Address - Street 1:1812 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4602
Practice Address - Country:US
Practice Address - Phone:360-584-5078
Practice Address - Fax:844-554-3370
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60987591175T00000X
WACO61000223101Y00000X
WACP61505739101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2140147Medicaid