Provider Demographics
NPI:1194093039
Name:JOHNSON, RONN (PHD, ABPP)
Entity type:Individual
Prefix:DR
First Name:RONN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 CASSIDY ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5314
Mailing Address - Country:US
Mailing Address - Phone:760-721-2171
Mailing Address - Fax:
Practice Address - Street 1:321 CASSIDY ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5314
Practice Address - Country:US
Practice Address - Phone:760-721-2171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11764103TC0700X, 103TF0200X
MA8969103TC0700X
NY010201103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic