Provider Demographics
NPI:1144774662
Name:JOHNSON, ELIZABETH X
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:JOHNSON
Suffix:X
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:ROSE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1031
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-0035
Mailing Address - Country:US
Mailing Address - Phone:909-597-1821
Mailing Address - Fax:
Practice Address - Street 1:14901 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-9500
Practice Address - Country:US
Practice Address - Phone:909-597-1821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 207561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical