Provider Demographics
NPI:1053709600
Name:JOHNSON, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23500 KASSON RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23500 KASSON RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95304-9595
Practice Address - Country:US
Practice Address - Phone:209-835-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA