Provider Demographics
NPI:1518025907
Name:JOHNSON, BRENDA ROLAND (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:ROLAND
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-0326
Mailing Address - Country:US
Mailing Address - Phone:858-455-7333
Mailing Address - Fax:
Practice Address - Street 1:990 HIGHLAND DR
Practice Address - Street 2:STE 103
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2409
Practice Address - Country:US
Practice Address - Phone:858-455-7333
Practice Address - Fax:858-455-5747
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR16444Medicare ID - Type Unspecified