Provider Demographics
NPI:1295253953
Name:JOHNSON, RAPHAEL GIDHARRY (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:GIDHARRY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1753 N. COUNTRY LN.
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1104
Mailing Address - Country:US
Mailing Address - Phone:213-700-4324
Mailing Address - Fax:626-797-7064
Practice Address - Street 1:1753 N. COUNTRY LN.
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1104
Practice Address - Country:US
Practice Address - Phone:213-700-4324
Practice Address - Fax:626-797-7064
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-01
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24051103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)