Basic Information
| Provider Information | |||||||||
| NPI: | 1669530374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | STANLEY | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1409 GRACE AVENUE | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 6TH STREET SE | ||||||||
| Address2: | WOODLAND CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202319148 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0052 | MN | X | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 0251 | MN | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30026JO | 01 | BLUE CROSS | OTHER | 115378 | 01 | UCARE | OTHER | 6220228 | 01 | UBH | OTHER | 1013100 | 01 | PREFERRED ONE | OTHER |