Healthcare Provider Details

I. General information

NPI: 1184010001
Provider Name (Legal Business Name): COURTNEY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST SUITE 250
SAN BERNARDINO CA
92408-2773
US

IV. Provider business mailing address

423 MACKAY DR
SAN BERNARDINO CA
92408-3230
US

V. Phone/Fax

Practice location:
  • Phone: 909-383-1073
  • Fax: 909-422-1073
Mailing address:
  • Phone: 909-383-1073
  • Fax: 909-422-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number34533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: