Provider Demographics
NPI:1114648680
Name:JOHNSON, TAMEKIA TENE
Entity type:Individual
Prefix:
First Name:TAMEKIA
Middle Name:TENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 PAVILION PKWY APT 1102
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9491
Mailing Address - Country:US
Mailing Address - Phone:510-365-6647
Mailing Address - Fax:
Practice Address - Street 1:3705 HAVEN AVE STE 112
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-1011
Practice Address - Country:US
Practice Address - Phone:916-642-9522
Practice Address - Fax:916-678-4138
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112085106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist