Provider Demographics
NPI:1447895602
Name:JOHNSON, KRISTIE LYNN (CP61134159)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CP61134159
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WALLA WALLA STATE PENITENTIARY
Mailing Address - Street 2:1313 N 13TH AVE
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-524-7509
Mailing Address - Fax:
Practice Address - Street 1:910 W BOONE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-5029
Practice Address - Country:US
Practice Address - Phone:095-325-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-12
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61134159101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)