Healthcare Provider Details

I. General information

NPI: 1548896848
Provider Name (Legal Business Name): LA WANDA JOHNSON PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 TRESTLE GLEN WAY
SACRAMENTO CA
95831-2737
US

IV. Provider business mailing address

962 TRESTLE GLEN WAY
SACRAMENTO CA
95831-2737
US

V. Phone/Fax

Practice location:
  • Phone: 619-665-1459
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number150135700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: