Basic Information
| Provider Information | |||||||||
| NPI: | 1326532284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BREANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 692547 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952692547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257594514 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 302 CHERRY LN STE 101 | ||||||||
| Address2: | |||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953374311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096476217 | ||||||||
| FaxNumber: | 2096476210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2018 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/02/2020 | ||||||||
| NPIReactivationDate: | 05/12/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 93896 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.