Healthcare Provider Details

I. General information

NPI: 1114126810
Provider Name (Legal Business Name): LISA MARIE JOHNSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST PSYCHIATRY/CASTLEMONT
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

2921 HAVENSCOURT BLVD
OAKLAND CA
94605-2024
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3885
  • Fax:
Mailing address:
  • Phone: 510-209-4161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: