Provider Demographics
NPI:1174657902
Name:JOHNSON, HEATHER JEAN (MA, MFT, PSYD)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, MFT, PSYD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:JEAN
Other - Last Name:GUMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17121 BLACK WALNUT CT
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-6237
Mailing Address - Country:US
Mailing Address - Phone:714-812-4991
Mailing Address - Fax:
Practice Address - Street 1:101 S KRAEMER BLVD
Practice Address - Street 2:STE 114
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-6109
Practice Address - Country:US
Practice Address - Phone:714-253-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29054106H00000X
CAPSY25944103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist