Provider Demographics
NPI:1588699847
Name:JOHNSON, RICHARD DAVID (PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 LEHMEN DR
Mailing Address - Street 2:PO BOX 31 CHESTER MENTAL HEALTH CENTER
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-2542
Mailing Address - Country:US
Mailing Address - Phone:618-826-4571
Mailing Address - Fax:618-826-3229
Practice Address - Street 1:1315 LEHMEN DR
Practice Address - Street 2:CHESTER MENTAL HEALTH CENTER
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-2542
Practice Address - Country:US
Practice Address - Phone:618-826-4571
Practice Address - Fax:618-826-3229
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203382Medicare PIN