Basic Information
| Provider Information | |||||||||
| NPI: | 1548290992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PSYCHOLOGIST-MASTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6213 VT ROUTE 14 | ||||||||
| Address2: | |||||||||
| City: | CRAFTSBURY COMMON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058279500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022794636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 607 WASHINTON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056618652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028888320 | ||||||||
| FaxNumber: | 8028888136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 000125 | VT | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TC2200X | 047-0000676 | VT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | OVN1866 | 05 | VT | MEDICAID |