Basic Information
| Provider Information | |||||||||
| NPI: | 1861142184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ALISON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R1462450322 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 453 S INDIANA ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900633908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232667726 | ||||||||
| FaxNumber: | 3232667742 | ||||||||
| Practice Location | |||||||||
| Address1: | 453 S INDIANA ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900633908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232667726 | ||||||||
| FaxNumber: | 3232667742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2022 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 01 | CA | SUBSTANCE ABUSE | OTHER |