Provider Demographics
NPI:1588207096
Name:JOHNSON, CHRISTA ROSE
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:ROSE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 YORBA LINDA BLVD APT 132
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1741
Mailing Address - Country:US
Mailing Address - Phone:562-458-3190
Mailing Address - Fax:
Practice Address - Street 1:1940 E DEERE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5718
Practice Address - Country:US
Practice Address - Phone:714-742-1781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7001101YM0800X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health