Healthcare Provider Details

I. General information

NPI: 1770788697
Provider Name (Legal Business Name): DOUGLAS CHRISTIAN JOHNSON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8939 VILLA LA JOLLA DR SUITE #230
LA JOLLA CA
92037-1732
US

IV. Provider business mailing address

8939 VILLA LA JOLLA DR SUITE #230
LA JOLLA CA
92037-1732
US

V. Phone/Fax

Practice location:
  • Phone: 858-999-4287
  • Fax:
Mailing address:
  • Phone: 858-999-4287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY21975
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY21975
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21975
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: