Provider Demographics
NPI:1588402424
Name:JOHNSON, SAMANTHA JANINE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANINE
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 1:2470 STEARNS ST # 206
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31450 BROAD BEACH RD
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2669
Practice Address - Country:US
Practice Address - Phone:310-881-8457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147424106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist