Provider Demographics
NPI:1619107109
Name:RAYMAN, JOHANNA R (LCSW, GCFP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:R
Last Name:RAYMAN
Suffix:
Gender:F
Credentials:LCSW, GCFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 NE HANCOCK ST
Mailing Address - Street 2:STE 207
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5321
Mailing Address - Country:US
Mailing Address - Phone:503-380-5437
Mailing Address - Fax:888-974-1510
Practice Address - Street 1:5404 N MONTANA AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4557
Practice Address - Country:US
Practice Address - Phone:503-380-5437
Practice Address - Fax:888-974-1510
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3575174400000X
ORL38431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR520079000OtherREGENCE BLUECROSS BLUESHIELD OF OREGON
OR164936Medicaid