Provider Demographics
NPI:1326369828
Name:JOHNSON, JUSTINE HATIE (IMF 61085)
Entity Type:Individual
Prefix:MS
First Name:JUSTINE
Middle Name:HATIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:IMF 61085
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2739 DERRFORD STREET
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712
Mailing Address - Country:US
Mailing Address - Phone:562-726-6213
Mailing Address - Fax:562-612-1476
Practice Address - Street 1:2739 DEERFORD ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-3307
Practice Address - Country:US
Practice Address - Phone:562-726-6213
Practice Address - Fax:562-612-1476
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61085106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist