Provider Demographics
NPI:1083379903
Name:JOHNSON, SCOTT DAVID
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
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 1:3050 DUNDEE AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-1803
Mailing Address - Country:US
Mailing Address - Phone:909-838-9616
Mailing Address - Fax:
Practice Address - Street 1:18612 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-2639
Practice Address - Country:US
Practice Address - Phone:909-421-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1419230221101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty