Provider Demographics
NPI:1962109066
Name:LONGERO, JOHANNA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:LONGERO
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 1:1841 OREGON DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-2628
Mailing Address - Country:US
Mailing Address - Phone:916-600-5276
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-9283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA798111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1041C0700XMedicaid