Provider Demographics
NPI:1912124686
Name:JOHNSON, KRISTIE (MFT)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 WASHINGTON ST # 203
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-2704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2023 N ST STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-4240
Practice Address - Country:US
Practice Address - Phone:916-542-2464
Practice Address - Fax:949-404-6919
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#