Provider Demographics
NPI:1073886248
Name:JOHNSON, GREG MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:MICHAEL
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 1:12024 E PLEASANT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-8503
Mailing Address - Country:US
Mailing Address - Phone:734-474-1542
Mailing Address - Fax:
Practice Address - Street 1:142 E MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2735
Practice Address - Country:US
Practice Address - Phone:517-263-5810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012855103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist