Provider Demographics
NPI:1679308258
Name:JOHNASEN, LLYR TOBIAS
Entity type:Individual
Prefix:
First Name:LLYR
Middle Name:TOBIAS
Last Name:JOHNASEN
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 1:735 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-1254
Mailing Address - Country:US
Mailing Address - Phone:310-776-5597
Mailing Address - Fax:
Practice Address - Street 1:2426 7TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-3912
Practice Address - Country:US
Practice Address - Phone:310-776-5597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health