Provider Demographics
NPI:1144354978
Name:JOHNSON, DOUGLAS
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
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 1:3737 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 612
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3513
Mailing Address - Country:US
Mailing Address - Phone:310-603-2795
Mailing Address - Fax:
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 612
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:310-603-2795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19213103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent