Provider Demographics
NPI:1053899120
Name:JOHNSON, AUDREY LYNN (RADT-1)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 LAGUNA PARK DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5241
Mailing Address - Country:US
Mailing Address - Phone:916-802-2629
Mailing Address - Fax:
Practice Address - Street 1:4343 WILLIAMSBOURGH DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2006
Practice Address - Country:US
Practice Address - Phone:916-714-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)