Provider Demographics
NPI:1932732971
Name:JOHNSON, MERCEDES CHANEL
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:CHANEL
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 1:3 SAN LUIS PL
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-2806
Mailing Address - Country:US
Mailing Address - Phone:843-450-4312
Mailing Address - Fax:
Practice Address - Street 1:3 SAN LUIS PL
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-2806
Practice Address - Country:US
Practice Address - Phone:843-450-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0OtherDON'T HAVE MEDICAL