Provider Demographics
NPI:1639531965
Name:JOHNSON, STEPHANIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N MOUNTAIN AVE STE 110B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5714
Mailing Address - Country:US
Mailing Address - Phone:909-999-5220
Mailing Address - Fax:
Practice Address - Street 1:222 N MOUNTAIN AVE STE 110B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5714
Practice Address - Country:US
Practice Address - Phone:909-999-5220
Practice Address - Fax:909-781-2422
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30152103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX74-16142229OtherUS DEPARTMENT OF VETERAN AFFAIRS