Provider Demographics
NPI: | 1922666346 |
---|---|
Name: | JOHNSON, TRASHANAY LAKEYA |
Entity Type: | Individual |
Prefix: | |
First Name: | TRASHANAY |
Middle Name: | LAKEYA |
Last Name: | JOHNSON |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 15374 COLEEN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | FONTANA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92337-9040 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 15374 COLEEN ST |
Practice Address - Street 2: | |
Practice Address - City: | FONTANA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92337-9040 |
Practice Address - Country: | US |
Practice Address - Phone: | 714-592-4253 |
Practice Address - Fax: | 714-592-4253 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2019-05-31 |
Last Update Date: | 2020-05-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
103K00000X | ||
CA | 103K00000X, 103TF0000X, 106S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 106S00000X | Behavioral Health & Social Service Providers | Behavior Technician | |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | |
No | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 1922666346 | Other | NPI |