Provider Demographics
NPI:1558695718
Name:JOHANSEN, IAN THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:THOMAS
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:17215 STUDEBAKER RD
Mailing Address - Street 2:SUITE #110
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2548
Mailing Address - Country:US
Mailing Address - Phone:562-860-2210
Mailing Address - Fax:562-860-1154
Practice Address - Street 1:17215 STUDEBAKER RD
Practice Address - Street 2:SUITE #110
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2548
Practice Address - Country:US
Practice Address - Phone:562-860-2210
Practice Address - Fax:562-860-1154
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22833103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical