MEDICARE: CLARISSA JOY 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

General Provider Information

NPI Number	:	1689384786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA JOY JOHNSON

Provider Business Mailing Address
First Line	:	4141 S NOGALES ST
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3056
Country	:	US
Telephone Number	:	833-831-8946
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 S NOGALES ST
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3056
Country	:	US
Telephone Number	:	833-831-8946
Fax Number	:

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

Provider Enumeration Date	:	11/29/2022
Last Update Date	:	11/29/2022

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