Provider Demographics
NPI:1225785660
Name:JOHNSON, GEORGE WILLIAM IV
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 ARNOLD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-4189
Mailing Address - Country:US
Mailing Address - Phone:888-678-7277
Mailing Address - Fax:
Practice Address - Street 1:1340 ARNOLD DR STE 200
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4189
Practice Address - Country:US
Practice Address - Phone:888-678-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health