Provider Demographics
NPI:1083635890
Name:RAYMAN, JOHANNA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:
Last Name:RAYMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 E TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5716
Mailing Address - Country:US
Mailing Address - Phone:309-662-2191
Mailing Address - Fax:309-661-7626
Practice Address - Street 1:200 W MONROE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3997
Practice Address - Country:US
Practice Address - Phone:309-310-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL572-8109OtherBLUE CROSS BLUE SHIELD IL
IL572-8109OtherBLUE CROSS BLUE SHIELD IL