Basic Information
| Provider Information | |||||||||
| NPI: | 1962709535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KALEAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 CHURCH LN | ||||||||
| Address2: | |||||||||
| City: | SAN PABLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948063707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102363139 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 251 GEORGIA ST | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945905905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075588500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT INTERN # 64702 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | AMFT98470 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.