Provider Demographics
NPI:1982182960
Name:JOHNSON, FREDERICK IV
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:JOHNSON
Suffix:IV
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:FREDDIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21600 OXNARD ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-7807
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:27777 INKSTER RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5312
Practice Address - Country:US
Practice Address - Phone:248-256-5214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician