Provider Demographics
NPI:1083353221
Name:JOHNSON, MATTHEW RONALD (LLMSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RONALD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 GLENWOOD CRK
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4842
Mailing Address - Country:US
Mailing Address - Phone:248-563-6685
Mailing Address - Fax:
Practice Address - Street 1:16836 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1600
Practice Address - Country:US
Practice Address - Phone:734-464-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511149191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical