Healthcare Provider Details

I. General information

NPI: 1790283877
Provider Name (Legal Business Name): MARINA JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 E AVENUE I STE 108
LANCASTER CA
93535-1941
US

IV. Provider business mailing address

11301 WILSHIRE BLVD # 122
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 661-729-8655
  • Fax:
Mailing address:
  • Phone: 661-729-8655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number81130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: