Provider Demographics
NPI:1528383494
Name:JOHNSON, VIRGINIA GAIL (MFT)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:GAIL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 D ST
Mailing Address - Street 2:#211
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3707
Mailing Address - Country:US
Mailing Address - Phone:415-454-4644
Mailing Address - Fax:
Practice Address - Street 1:711 D ST
Practice Address - Street 2:#211
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3707
Practice Address - Country:US
Practice Address - Phone:415-454-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33724106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist