Provider Demographics
NPI:1568131985
Name:JOHNSON, MARIAN KAYE (APCC)
Entity Type:Individual
Prefix:MS
First Name:MARIAN
Middle Name:KAYE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APCC
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 1403
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-1403
Mailing Address - Country:US
Mailing Address - Phone:916-652-0171
Mailing Address - Fax:
Practice Address - Street 1:3580 SHALLOW CREEK ROAD
Practice Address - Street 2:
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650-9565
Practice Address - Country:US
Practice Address - Phone:916-652-0516
Practice Address - Fax:916-652-3979
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC9258101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health