Provider Demographics
NPI:1265670103
Name:JOHNSON, TONY L (MFT)
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 SOUTHPOINT BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-7495
Mailing Address - Country:US
Mailing Address - Phone:707-763-4915
Mailing Address - Fax:
Practice Address - Street 1:720 SOUTHPOINT BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-7495
Practice Address - Country:US
Practice Address - Phone:707-763-4915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC16373106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist