Provider Demographics
NPI:1619220498
Name:PINA, JOHANNA IVETTE (BCBA)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:IVETTE
Last Name:PINA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:IVETTE
Other - Last Name:SANTOS RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:9355 E STOCKTON BLVD STE 225
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9355 E STOCKTON BLVD STE 225
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9526
Practice Address - Country:US
Practice Address - Phone:925-448-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66582101YP2500X
CA1-17-28059103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional