Provider Demographics
NPI:1184010001
Name:JOHNSON, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
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 1:423 MACKAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3230
Mailing Address - Country:US
Mailing Address - Phone:909-383-1073
Mailing Address - Fax:909-422-1073
Practice Address - Street 1:2080 S E ST
Practice Address - Street 2:SUITE 250
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2773
Practice Address - Country:US
Practice Address - Phone:909-383-1073
Practice Address - Fax:909-422-1073
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34533167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician