Provider Demographics
NPI:1528413549
Name:JOHNSON, RUSSELL D
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC, LISAC
Mailing Address - Street 1:2238 E. GINTER ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706
Mailing Address - Country:US
Mailing Address - Phone:520-545-2137
Mailing Address - Fax:520-545-2120
Practice Address - Street 1:2238 E. GINTER ROAD
Practice Address - Street 2:SUNNYSIDE UNIFIED SCHOOL DISTRICT NO. 12
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706
Practice Address - Country:US
Practice Address - Phone:520-545-2137
Practice Address - Fax:520-545-2120
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-0052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health