Provider Demographics
NPI:1124579545
Name:JOHNSON, RUDOLPH JR (CATC1)
Entity Type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:CATC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6537 REFLECTION DR APT 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3111
Mailing Address - Country:US
Mailing Address - Phone:619-727-7797
Mailing Address - Fax:
Practice Address - Street 1:6537 REFLECTION DR APT 105
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3111
Practice Address - Country:US
Practice Address - Phone:619-727-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility