Provider Demographics
NPI:1235966607
Name:JOHNSON, SAMANTHA ROSE (MED)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 146TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-6652
Mailing Address - Country:US
Mailing Address - Phone:952-380-7185
Mailing Address - Fax:
Practice Address - Street 1:150 W 1ST ST STE 270
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1770
Practice Address - Country:US
Practice Address - Phone:715-246-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8126-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional