Provider Demographics
NPI:1508345745
Name:JOHNSON, LORETTA
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LORETTA
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:1164 CAREY DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4336
Mailing Address - Country:US
Mailing Address - Phone:850-933-9370
Mailing Address - Fax:
Practice Address - Street 1:1164 CAREY DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-4336
Practice Address - Country:US
Practice Address - Phone:850-933-9370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid