Healthcare Provider Details

I. General information

NPI: 1891061925
Provider Name (Legal Business Name): GWENDOLYN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N LAKE AVE
PASADENA CA
91104-4521
US

IV. Provider business mailing address

2403 EL MOLINO AVE
ALTADENA CA
91001-2315
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-9746
  • Fax:
Mailing address:
  • Phone: 626-390-3877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: