Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker |
NPI | 1003242173 |
---|---|
Provider Name | Heather Irene Johnson |
First Address | Roseburg, OR 97470-0254 |
Second Address | Roseburg, OR 97470-3090 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2013 |
Last Update Date | 16/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
500663460 | (05) | OR |