MEDICARE: BRANDI LAUREN JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		CA

General Provider Information

NPI Number	:	1063051977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI LAUREN JOHNSON

Provider Business Mailing Address
First Line	:	3350 SHELBY ST
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91764-4882
Country	:	US
Telephone Number	:	844-423-3234
Fax Number	:

Provider Business Practice Location Address
First Line	:	3350 SHELBY ST
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91764-4882
Country	:	US
Telephone Number	:	844-423-3234
Fax Number	:	888-311-5333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2019
Last Update Date	:	12/26/2019

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