Provider Demographics
NPI:1053525873
Name:JOHNSON, MARTY CHRISTINE (LMFT CA)
Entity type:Individual
Prefix:MS
First Name:MARTY
Middle Name:CHRISTINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMFT CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1643
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-1643
Mailing Address - Country:US
Mailing Address - Phone:707-964-6164
Mailing Address - Fax:
Practice Address - Street 1:331 E. REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-964-6164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist