Provider Demographics
NPI:1346766862
Name:JOHNSON, VICTORIA G (LBA)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3411 WHITMAN DR
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1204
Mailing Address - Country:US
Mailing Address - Phone:281-676-2557
Mailing Address - Fax:318-855-1277
Practice Address - Street 1:4210 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-4118
Practice Address - Country:US
Practice Address - Phone:318-600-6640
Practice Address - Fax:318-855-1277
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-219103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL-219Medicaid