Provider Demographics
NPI:1972658862
Name:JOHNSON, DEBORA L (MS, CCC-A)
Entity Type:Individual
Prefix:MS
First Name:DEBORA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 RAINTREE CIR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4477
Mailing Address - Country:US
Mailing Address - Phone:213-309-4099
Mailing Address - Fax:
Practice Address - Street 1:1700 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-1727
Practice Address - Country:US
Practice Address - Phone:909-397-9247
Practice Address - Fax:909-397-9248
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1411231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0014110Medicaid