=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700273950
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. GORETHA JOHNSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 04/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12960 SAN PABLO AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94805-1307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-215-2280
-----------------------------------------------------
Fax | 510-215-2283
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4101 LEKE WAY
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94806-1753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-210-8285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------