Provider Demographics
NPI:1003085309
Name:JOHANSEN, RICKY LEE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:LEE
Last Name:JOHANSEN
Suffix:JR
Gender:M
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:PO BOX 3185
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-3185
Mailing Address - Country:US
Mailing Address - Phone:360-357-4707
Mailing Address - Fax:360-357-4707
Practice Address - Street 1:3727 PRINCETON CT SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-4150
Practice Address - Country:US
Practice Address - Phone:360-357-4707
Practice Address - Fax:360-357-4707
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health