Provider Demographics
NPI:1548387517
Name:JOHNSON, JOHN W (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7231 BOULDER AVE # 128
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3313
Mailing Address - Country:US
Mailing Address - Phone:626-644-7944
Mailing Address - Fax:626-463-1461
Practice Address - Street 1:3827 E COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3935
Practice Address - Country:US
Practice Address - Phone:626-644-7944
Practice Address - Fax:626-463-1461
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19013103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP19013Medicare ID - Type Unspecified