Healthcare Provider Details

I. General information

NPI: 1104593771
Provider Name (Legal Business Name): TIFFANY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2833 TENNESSEE ST
VALLEJO CA
94591-4948
US

IV. Provider business mailing address

3093 BROADWAY UNIT 432
OAKLAND CA
94611-5791
US

V. Phone/Fax

Practice location:
  • Phone: 707-556-8620
  • Fax:
Mailing address:
  • Phone: 805-286-8436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: