Provider Demographics
NPI:1821780370
Name:JOHNSON, MATTHEW CONRAD (MA, AMFT 142969)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CONRAD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, AMFT 142969
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, AMFT
Mailing Address - Street 1:PO BOX 862
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-0900
Mailing Address - Country:US
Mailing Address - Phone:619-909-8363
Mailing Address - Fax:
Practice Address - Street 1:10201 MISSION GORGE RD STE O
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3040
Practice Address - Country:US
Practice Address - Phone:619-383-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 171400000X
CA142969106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAMFT142969OtherBOARD OF BEHAVIORAL SCIENCES