Provider Demographics
NPI:1104254127
Name:JOHNSON, SHANA (ACSW)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:ACSW
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDCC-II
Mailing Address - Street 1:2921 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-3107
Mailing Address - Country:US
Mailing Address - Phone:818-521-8614
Mailing Address - Fax:
Practice Address - Street 1:13585 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3863
Practice Address - Country:US
Practice Address - Phone:818-521-8614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAASW1202691041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00OtherAC BHCS CLINICIAN # 00