Provider Demographics
NPI:1891893145
Name:JOHANSSON, MARY TAYLOR (MSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TAYLOR
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11661 SAN VICENTE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5110
Mailing Address - Country:US
Mailing Address - Phone:310-913-2983
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD BLDG 206 ROOM 33
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-913-2983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical