Provider Demographics
NPI:1689243826
Name:JOHNSON, CLARENCE WILLIE (MSW, ASW)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:WILLIE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW, ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 14TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3815
Mailing Address - Country:US
Mailing Address - Phone:951-358-4700
Mailing Address - Fax:
Practice Address - Street 1:15217 SAN BERNARDINO AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-5327
Practice Address - Country:US
Practice Address - Phone:951-643-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA983571041C0700X
98357101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical