Healthcare Provider Details

I. General information

NPI: 1174657902
Provider Name (Legal Business Name): HEATHER JEAN JOHNSON M.A., MFT, PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER JEAN GUMM

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S KRAEMER BLVD STE 114
PLACENTIA CA
92870-6109
US

IV. Provider business mailing address

17121 BLACK WALNUT CT
YORBA LINDA CA
92886-6237
US

V. Phone/Fax

Practice location:
  • Phone: 714-253-4104
  • Fax:
Mailing address:
  • Phone: 714-812-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC29054
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY25944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: