Provider Demographics
NPI:1962627901
Name:JOHANNSEN, CLIFFORD ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:ALAN
Last Name:JOHANNSEN
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 2004
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0626
Mailing Address - Country:US
Mailing Address - Phone:503-246-5986
Mailing Address - Fax:503-246-8050
Practice Address - Street 1:635 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2402
Practice Address - Country:US
Practice Address - Phone:503-399-9691
Practice Address - Fax:503-399-9401
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0935103T00000X, 103TA0400X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0200X, 103TP2701X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist