Healthcare Provider Details

I. General information

NPI: 1487782918
Provider Name (Legal Business Name): GENEVIEVE LYNN JOHANSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GENEVIEVE LYNN CHARLTON MSW

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40950 CHAPEL WAY
FREMONT CA
94538-4236
US

IV. Provider business mailing address

2275 ARLINGTON DR
SAN LEANDRO CA
94578-1132
US

V. Phone/Fax

Practice location:
  • Phone: 510-226-6180
  • Fax:
Mailing address:
  • Phone: 510-481-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25003
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: