Healthcare Provider Details

I. General information

NPI: 1770124497
Provider Name (Legal Business Name): ELISHA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38713 TIERRA SUBIDA AVE # 200336
PALMDALE CA
93551-4562
US

IV. Provider business mailing address

38713 TIERRA SUBIDA AVE # 200336
PALMDALE CA
93551-4562
US

V. Phone/Fax

Practice location:
  • Phone: 661-292-6301
  • Fax:
Mailing address:
  • Phone: 661-292-6301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT151530
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: