Provider Demographics
NPI:1730872961
Name:JOHNSON, VICTORIA (SOLE PROPRIETOR)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SOLE PROPRIETOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7406 S 29TH LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-9302
Mailing Address - Country:US
Mailing Address - Phone:480-823-2751
Mailing Address - Fax:
Practice Address - Street 1:2920 N 24TH AVE STE 270
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5961
Practice Address - Country:US
Practice Address - Phone:602-679-3465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness