Provider Demographics
NPI:1417074121
Name:JOHNSON, MICHELLE GABRIELLE
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:GABRIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:GABRIELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:9990 COUNTY FARM RD
Mailing Address - Street 2:5
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3542
Mailing Address - Country:US
Mailing Address - Phone:951-358-4840
Mailing Address - Fax:
Practice Address - Street 1:9990 COUNTY FARM RD
Practice Address - Street 2:5
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3542
Practice Address - Country:US
Practice Address - Phone:951-358-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health