Provider Demographics
NPI:1720363229
Name:JOHNSON, BRANDON L
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:L
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 1:21041 PARTHENIA ST
Mailing Address - Street 2:# 207
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-2078
Mailing Address - Country:US
Mailing Address - Phone:562-281-2463
Mailing Address - Fax:
Practice Address - Street 1:21041 PARTHENIA AVE
Practice Address - Street 2:# 207
Practice Address - City:CANOGA
Practice Address - State:CA
Practice Address - Zip Code:91325
Practice Address - Country:US
Practice Address - Phone:562-281-2463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA453418895101YA0400X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)