Provider Demographics
NPI:1457829251
Name:JOHNSON, DIANTAE RASHAD
Entity Type:Individual
Prefix:
First Name:DIANTAE
Middle Name:RASHAD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5375 YELLOW PINE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 GRAND CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8107
Practice Address - Country:US
Practice Address - Phone:888-512-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2019-08-21
Deactivation Date:2019-03-05
Deactivation Code:
Reactivation Date:2019-03-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician