Provider Demographics
NPI:1720696453
Name:JOHNSON, DOMINIC ROBERT
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-2305
Mailing Address - Country:US
Mailing Address - Phone:209-756-2736
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN STE 200
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2349
Practice Address - Country:US
Practice Address - Phone:650-243-9849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician