Provider Demographics
NPI:1841043890
Name:JOHNSON, ETHEL RENEE
Entity type:Individual
Prefix:MS
First Name:ETHEL
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221510
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91322-1510
Mailing Address - Country:US
Mailing Address - Phone:661-255-7963
Mailing Address - Fax:
Practice Address - Street 1:8144 ESCONDIDO CANYON RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:CA
Practice Address - Zip Code:93510-1534
Practice Address - Country:US
Practice Address - Phone:661-678-3894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator