Healthcare Provider Details

I. General information

NPI: 1992957971
Provider Name (Legal Business Name): KENT EVAN JOHNSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 WILSHIRE BLVD
LOS ANGELES CA
90057-4303
US

IV. Provider business mailing address

2500 WILSHIRE BLVD
LOS ANGELES CA
90057
US

V. Phone/Fax

Practice location:
  • Phone: 213-380-9531
  • Fax:
Mailing address:
  • Phone: 213-380-9531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number1568648590
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: