Provider Demographics
NPI:1316563596
Name:JOHNSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 S CITRUS AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4749
Mailing Address - Country:US
Mailing Address - Phone:850-393-6059
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4296
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1521070823101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)