Basic Information
| Provider Information | |||||||||
| NPI: | 1326668518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRYCE | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MS AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 354 S HALCYON RD | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054747043 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 354 S HALCYON RD | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054737060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2020 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.