Healthcare Provider Details

I. General information

NPI: 1477485944
Provider Name (Legal Business Name): DUSTIN RILEY JOHNSON LSWAIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 WOODLAND SQUARE LOOP SE STE 320
LACEY WA
98503-1066
US

IV. Provider business mailing address

PO BOX 144
SATSOP WA
98583-0144
US

V. Phone/Fax

Practice location:
  • Phone: 206-572-7308
  • Fax:
Mailing address:
  • Phone: 206-572-7308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWIA.SC.70112918
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: