Healthcare Provider Details

I. General information

NPI: 1467765743
Provider Name (Legal Business Name): TRASIE ENISE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S LONG BEACH BLVD
COMPTON CA
90221-4026
US

IV. Provider business mailing address

623 S. LONG BEACH BLVD.
COMPTON CA
90221-4026
US

V. Phone/Fax

Practice location:
  • Phone: 310-637-0341
  • Fax:
Mailing address:
  • Phone: 310-637-0341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRS5950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: