Provider Demographics
NPI:1639813520
Name:JOHNSON, MARVIN TYLER
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:TYLER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28085 WHITES CANYON RD APT 91
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-1286
Mailing Address - Country:US
Mailing Address - Phone:661-974-9113
Mailing Address - Fax:
Practice Address - Street 1:27200 TOURNEY RD STE 255
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4983
Practice Address - Country:US
Practice Address - Phone:661-222-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician