Healthcare Provider Details

I. General information

NPI: 1093540700
Provider Name (Legal Business Name): LAINE JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 TRANCAS ST UNIT 2216
NAPA CA
94558-7705
US

IV. Provider business mailing address

33175 TEMECULA PKWY # 532
TEMECULA CA
92592-7310
US

V. Phone/Fax

Practice location:
  • Phone: 310-734-0593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: