Provider Demographics
NPI:1104393149
Name:JOHNSON, DOMINIC IDRIS
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:IDRIS
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 1:2157 HILLRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7950
Mailing Address - Country:US
Mailing Address - Phone:707-344-1611
Mailing Address - Fax:
Practice Address - Street 1:150 GLEN COVE MARINA RD E STE 102
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7237
Practice Address - Country:US
Practice Address - Phone:707-553-1784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst