Provider Demographics
NPI:1508116237
Name:JOHNSON, REBECCA MARIE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:MARIE
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 1:21 TAMAL VISTA BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1130
Mailing Address - Country:US
Mailing Address - Phone:415-820-1612
Mailing Address - Fax:415-747-8479
Practice Address - Street 1:21 TAMAL VISTA BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1130
Practice Address - Country:US
Practice Address - Phone:415-820-1612
Practice Address - Fax:415-747-8479
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA79769OtherLICENSED MARRIAGE & FAMILY THERPAIST NUMBER
CA941735064OtherNOVATO YOUTH CENTER, EMPLOYER INFORMATION NUMBER, EIN