Provider Demographics
NPI:1063992162
Name:JOHANSSON, SONJA KUBOTA (PSYD)
Entity type:Individual
Prefix:
First Name:SONJA
Middle Name:KUBOTA
Last Name:JOHANSSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 EVERETT AVE APT 115
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-1515
Mailing Address - Country:US
Mailing Address - Phone:212-731-9293
Mailing Address - Fax:
Practice Address - Street 1:866 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305
Practice Address - Country:US
Practice Address - Phone:212-731-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC724196898Medicaid