Provider Demographics
NPI:1184241101
Name:JOHNSON, DIANE MAE (SUD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 E MADISON AVE SPC 24
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-8535
Mailing Address - Country:US
Mailing Address - Phone:619-753-0850
Mailing Address - Fax:
Practice Address - Street 1:455 K ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4107
Practice Address - Country:US
Practice Address - Phone:707-464-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty