Provider Demographics
NPI:1326532284
Name:JOHNSON, BREANA (ASW)
Entity Type:Individual
Prefix:
First Name:BREANA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 692547
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95269-2547
Mailing Address - Country:US
Mailing Address - Phone:925-759-4514
Mailing Address - Fax:
Practice Address - Street 1:302 CHERRY LN STE 101
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4311
Practice Address - Country:US
Practice Address - Phone:209-647-6217
Practice Address - Fax:209-647-6210
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2022-10-05
Deactivation Date:2020-05-02
Deactivation Code:
Reactivation Date:2020-05-12
Provider Licenses
StateLicense IDTaxonomies
CA93896104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program