Provider Demographics
NPI:1720601446
Name:JOHNSON, ANYSSIA
Entity Type:Individual
Prefix:
First Name:ANYSSIA
Middle Name:
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 1:1214 EDDINGTON ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3440
Mailing Address - Country:US
Mailing Address - Phone:909-931-1137
Mailing Address - Fax:
Practice Address - Street 1:1214 EDDINGTON ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3440
Practice Address - Country:US
Practice Address - Phone:909-931-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116541106H00000X
106H00000X
CA135166106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist