Healthcare Provider Details

I. General information

NPI: 1275075269
Provider Name (Legal Business Name): BLAKE QUINTON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
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: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberACSW93874
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW93874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: