Provider Demographics
NPI:1861698169
Name:JOHNSON, MARIA CAVANAGH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:CAVANAGH
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 1:1101 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3290
Mailing Address - Country:US
Mailing Address - Phone:626-799-4522
Mailing Address - Fax:818-790-0139
Practice Address - Street 1:1101 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3290
Practice Address - Country:US
Practice Address - Phone:626-799-4522
Practice Address - Fax:818-790-0139
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9532103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist