Full Name | |
---|---|
Speciality | Psychologist |
Location | 336 Lodi St, Lodi, Wisconsin |
Authorized Official Name and Position | Ronald Bruce Johnson (OWNER/PARTNER) |
Authorized Official Contact | 6085922080 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
336 Lodi St Lodi WI 53555-1418 Ph: (608) 592-2080 | 336 Lodi St Lodi WI 53555-1418 Ph: (608) 592-2080 |
NPI Number | 1285676593 |
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Provider Enumeration Date | 06/12/2006 |
Last Update Date | 03/18/2013 |
Medicare PECOS PAC ID | 6901817956 |
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Medicare Enrollment ID | O20060505000509 |
Identifier | Type | State | Issuer |
---|---|---|---|
1285676593 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
103TC0700X | Psychologist - Clinical | (Wisconsin) | Primary |
Provider Name | Ronald B Johnson |
---|---|
Provider Type | Practitioner - Clinical Psychologist |
Provider Identifiers | NPI Number: 1598701906 PECOS PAC ID: 4082625033 Enrollment ID: I20060508000095 |