Healthcare Provider Details

I. General information

NPI: 1730619859
Provider Name (Legal Business Name): RONALD ROBERT JOHNSON LCAS (REGISTERED)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3826 BLAND RD
RALEIGH NC
27609
US

IV. Provider business mailing address

3111 LONG MEADOW CT APT 203
RALEIGH NC
27613-3216
US

V. Phone/Fax

Practice location:
  • Phone: 919-872-1441
  • Fax: 919-872-1455
Mailing address:
  • Phone: 919-436-0413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23707
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13636
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: