Healthcare Provider Details

I. General information

NPI: 1609348648
Provider Name (Legal Business Name): BRAQUE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 MARKET ST
VENTURA CA
93003-7783
US

IV. Provider business mailing address

530 EMMONS ST
SACRAMENTO CA
95838-2865
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-7598
  • Fax:
Mailing address:
  • Phone: 469-230-9496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY2880508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: