Provider Demographics
NPI:1568359313
Name:JOHNSON, AMANDA MEDRANO (LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MEDRANO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 TWILIGHT DR
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1409
Mailing Address - Country:US
Mailing Address - Phone:208-881-2658
Mailing Address - Fax:
Practice Address - Street 1:715 TWILIGHT DR
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1409
Practice Address - Country:US
Practice Address - Phone:208-881-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5672101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health