Provider Demographics
NPI:1306820915
Name:JOHNSON, RONALD STUART (PHD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:STUART
Last Name:JOHNSON
Suffix:
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 1:3702 WILLOW LAKE LN
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-1417
Mailing Address - Country:US
Mailing Address - Phone:580-234-8817
Mailing Address - Fax:
Practice Address - Street 1:320 YOUNG RD
Practice Address - Street 2:71 MDOS/SGOML BUILDING 248
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73705-5506
Practice Address - Country:US
Practice Address - Phone:580-213-7419
Practice Address - Fax:580-213-6423
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM635103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical