Provider Demographics
NPI:1619342516
Name:JOHNSON, LINDA LYNETTE
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:LYNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:LYNETTE
Other - Last Name:JOHNNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1730 GUM ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3028
Mailing Address - Country:US
Mailing Address - Phone:650-504-1650
Mailing Address - Fax:650-345-8957
Practice Address - Street 1:501 1ST AVE STE 3
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3476
Practice Address - Country:US
Practice Address - Phone:650-504-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89367106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist