Provider Demographics
NPI:1609860295
Name:JOHANSEN, ROBERT N (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:N
Last Name:JOHANSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:CA
Mailing Address - Zip Code:90702-2089
Mailing Address - Country:US
Mailing Address - Phone:562-866-1895
Mailing Address - Fax:562-866-5730
Practice Address - Street 1:17215 STUDEBAKER RD
Practice Address - Street 2:#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:562-860-2451
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10129103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY101290Medicaid
CAOPL101290OtherBLUE SHIELD
R14411Medicare UPIN
CAPSY101290Medicaid