Provider Demographics
NPI:1114043072
Name:JOHNSON, RANDY RAY
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:RAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8636 S 1700 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1412
Mailing Address - Country:US
Mailing Address - Phone:801-879-5579
Mailing Address - Fax:
Practice Address - Street 1:1226 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-302-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT117085-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist