Provider Demographics
NPI:1457482077
Name:JOHNSON, RICHARD POWELL (MA,CADCIII,NCGCII,)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:POWELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA,CADCIII,NCGCII,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 CERVANTES CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15630 SE 90TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9729
Practice Address - Country:US
Practice Address - Phone:971-235-2954
Practice Address - Fax:503-675-9988
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR96-04-104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR96-04-104OtherADDICTION COUNSELOR CERTIFICATION BOARD OF OREGON