Provider Demographics
NPI:1801314158
Name:JOHNSON, KATHLEEN GRUNBAUM
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRUNBAUM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:THERESA
Other - Last Name:GRUNBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:902 S MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3427
Mailing Address - Country:US
Mailing Address - Phone:626-357-3258
Mailing Address - Fax:626-303-0529
Practice Address - Street 1:902 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-1765
Practice Address - Country:US
Practice Address - Phone:626-357-3258
Practice Address - Fax:626-303-0529
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32661167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician