Provider Demographics
NPI:1861142184
Name:JOHNSON, MARY ALISON (R1462450322)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALISON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:R1462450322
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:453 S INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-3908
Mailing Address - Country:US
Mailing Address - Phone:323-266-7726
Mailing Address - Fax:323-266-7742
Practice Address - Street 1:17822 BEACH BLVD STE 278
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7180
Practice Address - Country:US
Practice Address - Phone:143-753-7957
Practice Address - Fax:714-375-3796
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YA0400XOtherSUBSTANCE ABUSE