Healthcare Provider Details

I. General information

NPI: 1821780370
Provider Name (Legal Business Name): MATTHEW CONRAD JOHNSON MA, AMFT 142969
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MATT JOHNSON MA, AMFT

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 MISSION GORGE RD STE O
SANTEE CA
92071-3040
US

IV. Provider business mailing address

PO BOX 862
LAKESIDE CA
92040-0900
US

V. Phone/Fax

Practice location:
  • Phone: 619-383-6868
  • Fax:
Mailing address:
  • Phone: 619-909-8363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number142969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: