Provider Demographics
NPI:1043828494
Name:JOHNSON, SYDNEY SIMONE
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:SIMONE
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 1:867 N FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3050
Mailing Address - Country:US
Mailing Address - Phone:626-379-5643
Mailing Address - Fax:
Practice Address - Street 1:867 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3050
Practice Address - Country:US
Practice Address - Phone:626-379-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120018106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist