Provider Demographics
NPI:1023366077
Name:JOHNSON, PRISCILLA E
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13102 BRENTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-7889
Mailing Address - Country:US
Mailing Address - Phone:951-255-4632
Mailing Address - Fax:
Practice Address - Street 1:13102 BRENTWOOD LN
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7889
Practice Address - Country:US
Practice Address - Phone:951-255-4632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker