Provider Demographics
NPI:1629737440
Name:JOHNSON, KIS'SARRIA EILISHA CORDIA
Entity Type:Individual
Prefix:
First Name:KIS'SARRIA
Middle Name:EILISHA CORDIA
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 1:1333 WILLOW PASS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-7931
Mailing Address - Country:US
Mailing Address - Phone:925-825-1793
Mailing Address - Fax:
Practice Address - Street 1:3095 RICHMOND PKWY STE 201
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-5878
Practice Address - Country:US
Practice Address - Phone:510-778-2816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health