Provider Demographics
NPI:1720293426
Name:JOHNSON, DANIELLE LYNN (MED)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 W BEHREND DR APT 2079
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6951
Mailing Address - Country:US
Mailing Address - Phone:623-376-3701
Mailing Address - Fax:623-376-3780
Practice Address - Street 1:41020 N FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-2520
Practice Address - Country:US
Practice Address - Phone:623-376-3701
Practice Address - Fax:623-376-3780
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool