MEDICARE: DR. PERRI JOHNSON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY14431	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PSY14431	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1790904944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PERRI JOHNSON PH.D.

Provider Business Mailing Address
First Line	:	3330 BARHAM BLVD
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-1400
Country	:	US
Telephone Number	:	323-512-7150
Fax Number	:	323-512-2041

Provider Business Practice Location Address
First Line	:	3330 BARHAM BLVD
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-1400
Country	:	US
Telephone Number	:	323-512-7150
Fax Number	:	323-512-2041

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/09/2007

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