Healthcare Provider Details

I. General information

NPI: 1174528210
Provider Name (Legal Business Name): RONALD R JOHNSON JR. PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2587 RAVENHILL DR
FAYETTEVILLE NC
28303-5451
US

IV. Provider business mailing address

2587 RAVENHILL DR
FAYETTEVILLE NC
28303-5451
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1543
  • Fax: 910-485-1257
Mailing address:
  • Phone: 910-323-1543
  • Fax: 910-485-1257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3148
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: