Provider Demographics
NPI:1891047171
Name:JOHNSON HOLLMAN, TINA LATRICE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LATRICE
Last Name:JOHNSON HOLLMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 BELDEN STREET, P.O. BOX 417
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:CA
Mailing Address - Zip Code:93926
Mailing Address - Country:US
Mailing Address - Phone:831-678-3951
Mailing Address - Fax:909-881-3871
Practice Address - Street 1:CORRECTIONAL TRAINING FACILITY, HWY 101
Practice Address - Street 2:
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960
Practice Address - Country:US
Practice Address - Phone:831-678-3951
Practice Address - Fax:909-881-3871
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA370051041C0700X
CA766571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker