Provider Demographics
NPI:1902295975
Name:JOHNSON, TRAVIS (PHD, LMFT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 MAPLEWOOD AVE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3596
Mailing Address - Country:US
Mailing Address - Phone:315-313-5979
Mailing Address - Fax:315-313-5979
Practice Address - Street 1:5019 MAPLEWOOD AVE UNIT 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3596
Practice Address - Country:US
Practice Address - Phone:315-313-5979
Practice Address - Fax:315-313-5979
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006640106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist