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General NPI Number Information
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NPI Number | 1104393149
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Entity Type | Individual
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Provider Name | DOMINIC IDRIS JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 10/29/2018
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Last Update Date | 10/29/2018
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Provider Practice Location Address
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Address Line | 150 GLEN COVE MARINA RD E STE 102
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City | VALLEJO
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State | CA
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Zip | 94591-7237
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Country | US
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Telephone | 707-553-1784
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Fax |
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Provider Business Mailing Address
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Address Line | 2157 HILLRIDGE DR
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City | FAIRFIELD
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State | CA
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Zip | 94534-7950
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Country | US
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Telephone | 707-344-1611
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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