Provider Demographics
NPI:1356584999
Name:JOHNSON, DEZARAE LEANN (ACSW, PPS)
Entity type:Individual
Prefix:
First Name:DEZARAE
Middle Name:LEANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ACSW, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93613-0335
Mailing Address - Country:US
Mailing Address - Phone:916-752-5890
Mailing Address - Fax:
Practice Address - Street 1:5271 W PALO ALTO AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-3635
Practice Address - Country:US
Practice Address - Phone:559-276-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88176104100000X, 101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator