Provider Demographics
NPI:1801584388
Name:JOHNSON, PASCAL ROQUE
Entity type:Individual
Prefix:
First Name:PASCAL
Middle Name:ROQUE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PASCAL
Other - Middle Name:ROQUE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3860 CRENSHAW BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1816
Mailing Address - Country:US
Mailing Address - Phone:323-593-5300
Mailing Address - Fax:
Practice Address - Street 1:4401 CRENSHAW BLVD STE 215
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1200
Practice Address - Country:US
Practice Address - Phone:323-291-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician