Provider Demographics
NPI:1457096570
Name:JOHNSON, CORY M (NONE)
Entity Type:Individual
Prefix:MR
First Name:CORY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4820
Mailing Address - Country:US
Mailing Address - Phone:714-342-8626
Mailing Address - Fax:
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1250
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4633
Practice Address - Country:US
Practice Address - Phone:949-357-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician