Provider Demographics
NPI:1437706587
Name:JOHNSON, THERESE MARIE (CEO)
Entity Type:Individual
Prefix:MISS
First Name:THERESE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12460 LADD LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-9571
Mailing Address - Country:US
Mailing Address - Phone:530-305-8872
Mailing Address - Fax:530-466-3133
Practice Address - Street 1:12460 LADD LN
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9571
Practice Address - Country:US
Practice Address - Phone:530-305-8872
Practice Address - Fax:530-466-3133
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAXXXXXXXXXXX171M00000X
CAXXXXXXXXXXXX171M00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator