Provider Demographics
NPI:1568041192
Name:JOHNSON, CHASITY DAUGHERTY7 (LEP, NCSP)
Entity Type:Individual
Prefix:
First Name:CHASITY
Middle Name:DAUGHERTY7
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LEP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8265 BALSA AVE
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-6112
Mailing Address - Country:US
Mailing Address - Phone:304-416-4339
Mailing Address - Fax:
Practice Address - Street 1:500 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589
Practice Address - Country:US
Practice Address - Phone:360-264-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3744103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty