Provider Demographics
NPI:1477920783
Name:JOHANNESSEN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JOHANNESSEN
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 1:6926 NE FOURTH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7369
Mailing Address - Country:US
Mailing Address - Phone:360-993-3000
Mailing Address - Fax:
Practice Address - Street 1:6926 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:OR
Practice Address - Zip Code:98666
Practice Address - Country:US
Practice Address - Phone:360-933-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional