Healthcare Provider Details

I. General information

NPI: 1417878422
Provider Name (Legal Business Name): MS. RAYLENE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 1/2 W 80TH ST
LOS ANGELES CA
90044-5017
US

IV. Provider business mailing address

943 1/2 W 80TH ST
LOS ANGELES CA
90044-5017
US

V. Phone/Fax

Practice location:
  • Phone: 424-236-1588
  • Fax:
Mailing address:
  • Phone: 424-236-1588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number260139357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: