Provider Demographics
NPI:1659740975
Name:JOHNSON, ROSALYN MICHELE (CRC)
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:MICHELE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2930
Mailing Address - Country:US
Mailing Address - Phone:619-683-7423
Mailing Address - Fax:
Practice Address - Street 1:2864 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2930
Practice Address - Country:US
Practice Address - Phone:619-683-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
00120566225C00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health