Healthcare Provider Details

I. General information

NPI: 1285708677
Provider Name (Legal Business Name): MICHELE RENEE MADSON JOHNSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELE RENEE MANKER

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 09/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12929 POMERADO ROAD
POWAY CA
92064
US

IV. Provider business mailing address

13051 BRULE PLACE
POWAY CA
92064-5325
US

V. Phone/Fax

Practice location:
  • Phone: 619-985-7772
  • Fax: 858-842-1112
Mailing address:
  • Phone: 619-985-7772
  • Fax: 858-842-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS12373
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: