Provider Demographics
NPI:1023345105
Name:JOHNSON, PAUL WILLIAM
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2600
Mailing Address - Fax:206-302-2610
Practice Address - Street 1:600 BROADWAY
Practice Address - Street 2:SUITE 170
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5229
Practice Address - Country:US
Practice Address - Phone:206-302-2600
Practice Address - Fax:206-302-2610
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WACO60508447390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH99003227Medicaid
NH99003227Medicaid