Provider Demographics
NPI:1457566754
Name:JOHNSON, ROSS J
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 W GLENDALE AVE
Mailing Address - Street 2:GLENDALE HIGH SCHOOL
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301
Mailing Address - Country:US
Mailing Address - Phone:623-435-6200
Mailing Address - Fax:
Practice Address - Street 1:6216 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301
Practice Address - Country:US
Practice Address - Phone:623-435-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ622614Medicaid