Provider Demographics
NPI:1902357874
Name:JOHNSON, SAMUEL ALEXANDER (DBC, M-RAS, CSC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ALEXANDER
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DBC, M-RAS, CSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14619 MAVERICK PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7082
Mailing Address - Country:US
Mailing Address - Phone:760-684-3419
Mailing Address - Fax:
Practice Address - Street 1:16755 HUGHES RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4563
Practice Address - Country:US
Practice Address - Phone:760-684-3419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAJ1006181711101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)