Provider Demographics
NPI:1396811980
Name:JOHNSON, BRET KALE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:KALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 WATER ST STE F2
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4131
Mailing Address - Country:US
Mailing Address - Phone:831-426-8901
Mailing Address - Fax:408-868-9060
Practice Address - Street 1:550 WATER ST STE F2
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4131
Practice Address - Country:US
Practice Address - Phone:831-426-8901
Practice Address - Fax:408-868-9060
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10630103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL106300Medicare ID - Type Unspecified