Provider Demographics
NPI:1336797505
Name:JOHNSON, BREA ALEXANDRIA DIANE
Entity type:Individual
Prefix:
First Name:BREA
Middle Name:ALEXANDRIA DIANE
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 1:12500 BARKER CYPRESS RD APT 8202
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-8259
Mailing Address - Country:US
Mailing Address - Phone:330-612-2213
Mailing Address - Fax:
Practice Address - Street 1:2616 S LOOP W STE 260
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-0005
Practice Address - Country:US
Practice Address - Phone:713-666-7779
Practice Address - Fax:832-200-9819
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82506101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty