Provider Demographics
NPI:1043854813
Name:JOHNSON, MINDY LEE (LMSW)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:LEE
Other - Last Name:BONO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12265 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8613
Mailing Address - Country:US
Mailing Address - Phone:231-206-2434
Mailing Address - Fax:
Practice Address - Street 1:12265 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8613
Practice Address - Country:US
Practice Address - Phone:616-494-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011066541041C0700X
MI68010959031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical