Provider Demographics
NPI:1194170563
Name:JOHNSON, TIA LORRAINE
Entity type:Individual
Prefix:MS
First Name:TIA
Middle Name:LORRAINE
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 1:1416 BREWERTON DR APT 306
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-4014
Mailing Address - Country:US
Mailing Address - Phone:408-912-3769
Mailing Address - Fax:
Practice Address - Street 1:1416 BREWERTON DR #306
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833
Practice Address - Country:US
Practice Address - Phone:408-912-3769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst