Provider Demographics
NPI:1790904944
Name:JOHNSON, PERRI (PHD)
Entity Type:Individual
Prefix:DR
First Name:PERRI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 BARHAM BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-1400
Mailing Address - Country:US
Mailing Address - Phone:323-512-7150
Mailing Address - Fax:323-512-2041
Practice Address - Street 1:3330 BARHAM BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-1400
Practice Address - Country:US
Practice Address - Phone:323-512-7150
Practice Address - Fax:323-512-2041
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14431103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY144313Medicaid
CAPSY14431OtherLICENSE