Provider Demographics
NPI:1033518139
Name:JOHNSON, LISA (MS, CGC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 LANCASHIRE DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2582
Mailing Address - Country:US
Mailing Address - Phone:937-681-3212
Mailing Address - Fax:
Practice Address - Street 1:201 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2396
Practice Address - Country:US
Practice Address - Phone:650-249-9090
Practice Address - Fax:650-412-2305
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH70.000012170300000X
CAGC001052170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS