Provider Demographics
NPI:1417372442
Name:JOHNSON, SHANELLE D (LMFT)
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 EL CAJON BLVD # 129
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-7434
Mailing Address - Country:US
Mailing Address - Phone:619-343-9543
Mailing Address - Fax:619-713-2561
Practice Address - Street 1:7317 EL CAJON BLVD # 129
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-948-4116
Practice Address - Fax:619-713-2561
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105060106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist