Provider Demographics
NPI:1124666359
Name:JOHNSON, MAURICE D
Entity type:Individual
Prefix:
First Name:MAURICE
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 MOSSY BANK DR APT 6
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2383
Mailing Address - Country:US
Mailing Address - Phone:916-270-8899
Mailing Address - Fax:
Practice Address - Street 1:8086 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-5941
Practice Address - Country:US
Practice Address - Phone:949-337-1439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA021510116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty