Healthcare Provider Details

I. General information

NPI: 1124226808
Provider Name (Legal Business Name): IVAN ROSHAWIN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

IV. Provider business mailing address

840 N AVENUE 66
LOS ANGELES CA
90042-1508
US

V. Phone/Fax

Practice location:
  • Phone: 240-762-8330
  • Fax:
Mailing address:
  • Phone: 626-517-2368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: