Provider Demographics
NPI:1053909374
Name:JOHNSON, COLLEEN ANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 W CAMPBELL AVE # 248
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1535
Mailing Address - Country:US
Mailing Address - Phone:498-781-8434
Mailing Address - Fax:
Practice Address - Street 1:15 MARAVILLA CT
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1847
Practice Address - Country:US
Practice Address - Phone:408-781-8434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2021-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26234103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling