Provider Demographics
NPI:1285066753
Name:JOHNSON, LISA YVONNE
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:YVONNE
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 1:21828 S. AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745
Mailing Address - Country:US
Mailing Address - Phone:424-477-5225
Mailing Address - Fax:424-477-5146
Practice Address - Street 1:21828 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-3303
Practice Address - Country:US
Practice Address - Phone:424-477-5225
Practice Address - Fax:424-477-5146
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01-139400101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)