Provider Demographics
NPI:1629201793
Name:JOHNSON, MARY (LMFT)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 GREEN RIVER RD STE 117B
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-9437
Mailing Address - Country:US
Mailing Address - Phone:909-496-2465
Mailing Address - Fax:
Practice Address - Street 1:4740 GREEN RIVER RD STE 117B
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92878-9437
Practice Address - Country:US
Practice Address - Phone:951-523-0569
Practice Address - Fax:800-507-8563
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT88231106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty