Basic Information
| Provider Information | |||||||||
| NPI: | 1245448398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NYSHIA | ||||||||
| MiddleName: | NAVONNE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14420 CIVIC DR STE 4 | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923922384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604900109 | ||||||||
| FaxNumber: | 7607801561 | ||||||||
| Practice Location | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 21721 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCS 27853 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | ICAN766 | 01 | CA | LACDMH ID | OTHER |