Basic Information
| Provider Information | |||||||||
| NPI: | 1679080808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11361 BROOMFIELD LN APT 301 | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800215036 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11059 E BETHANY DR | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800142622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036172300 | ||||||||
| FaxNumber: | 3036172365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2018 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 14-303-0846 | 01 | CO | DRIVERS LICENSE | OTHER |