Provider Demographics
NPI:1346069663
Name:JOHNSON, RYAN ALLEN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 COLONY DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8392
Mailing Address - Country:US
Mailing Address - Phone:847-363-5296
Mailing Address - Fax:
Practice Address - Street 1:24W500 MAPLE AVE STE 216A
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6003
Practice Address - Country:US
Practice Address - Phone:630-423-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health