Provider Demographics
NPI:1831591197
Name:JOHNSON, RIELLE (PSYD)
Entity type:Individual
Prefix:
First Name:RIELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E ERIE ST STE 525-2216
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2740
Mailing Address - Country:US
Mailing Address - Phone:312-625-9051
Mailing Address - Fax:
Practice Address - Street 1:1 E ERIE ST STE 525-2216
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:312-625-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016228103TC0700X
IL071010076103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical