Provider Demographics
NPI:1003103268
Name:JOHNSON, LORI (PSYD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17834
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92623-7834
Mailing Address - Country:US
Mailing Address - Phone:949-534-2451
Mailing Address - Fax:
Practice Address - Street 1:16485 LAGUNA CANYON RD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3837
Practice Address - Country:US
Practice Address - Phone:949-534-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
CAPSY32738103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent