Provider Demographics
NPI:1598087967
Name:JOHNSON, ELLIE I (PSYD)
Entity Type:Individual
Prefix:MRS
First Name:ELLIE
Middle Name:I
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
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 290002
Mailing Address - Street 2:
Mailing Address - City:REPRESA
Mailing Address - State:CA
Mailing Address - Zip Code:95671-0002
Mailing Address - Country:US
Mailing Address - Phone:916-985-8610
Mailing Address - Fax:
Practice Address - Street 1:300 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-0002
Practice Address - Country:US
Practice Address - Phone:916-985-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24135103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical