Provider Demographics
NPI:1972758001
Name:JOHNSON, CHRISTA MARIE (PSYD)
Entity Type:Individual
Prefix:MS
First Name:CHRISTA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SMITH RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1939
Mailing Address - Country:US
Mailing Address - Phone:415-491-3056
Mailing Address - Fax:
Practice Address - Street 1:111 SMITH RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1939
Practice Address - Country:US
Practice Address - Phone:415-491-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY28259103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program