Provider Demographics
NPI:1467873505
Name:JOHNSON, DANIEL JOE
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JOE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DJ
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2747 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-5941
Mailing Address - Country:US
Mailing Address - Phone:707-312-0380
Mailing Address - Fax:
Practice Address - Street 1:2100 NAPA VALLEJO HWY BLDG 253M1M2
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6234
Practice Address - Country:US
Practice Address - Phone:707-257-1460
Practice Address - Fax:707-257-7524
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA280017AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility