Provider Demographics
NPI:1467772194
Name:JOHNSON, RAY C (MS, LPC, LISAC)
Entity Type:Individual
Prefix:MR
First Name:RAY
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5340 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2903
Mailing Address - Country:US
Mailing Address - Phone:602-274-0312
Mailing Address - Fax:602-274-0312
Practice Address - Street 1:5340 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2903
Practice Address - Country:US
Practice Address - Phone:602-274-0312
Practice Address - Fax:602-274-0312
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC - 11495101YA0400X
AZLPC - 10960101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional