Provider Demographics
NPI:1770001638
Name:JOHNSON, REGAN LYNN
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGAN
Other - Middle Name:LYNN
Other - Last Name:SHATTUCK-SMALLWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-501-5322
Mailing Address - Fax:503-726-5323
Practice Address - Street 1:10232 SE ANKENY ST APT C205
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-4617
Practice Address - Country:US
Practice Address - Phone:541-731-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health