Provider Demographics
NPI:1962524124
Name:JOHNSON, MONIQUE L (AS)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6978 SAGEBRUSH WAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1730
Mailing Address - Country:US
Mailing Address - Phone:951-237-6220
Mailing Address - Fax:
Practice Address - Street 1:10421 S FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-4423
Practice Address - Country:US
Practice Address - Phone:800-854-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist