Provider Demographics
NPI:1245448398
Name:JOHNSON, NYSHIA NAVONNE (LCSW)
Entity type:Individual
Prefix:
First Name:NYSHIA
Middle Name:NAVONNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14420 CIVIC DR STE 4
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2384
Mailing Address - Country:US
Mailing Address - Phone:760-490-0109
Mailing Address - Fax:760-780-1561
Practice Address - Street 1:15095 AMARGOSA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394
Practice Address - Country:US
Practice Address - Phone:760-245-4695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA217211041C0700X
CALCS 278531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN766OtherLACDMH ID