Provider Demographics
NPI:1124373352
Name:JOHNSON, COURTNEY J (LMSW, CAADC)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 GILCREST AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1843
Mailing Address - Country:US
Mailing Address - Phone:906-236-0569
Mailing Address - Fax:866-257-5918
Practice Address - Street 1:6701 OLD 28TH ST SE
Practice Address - Street 2:STE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6937
Practice Address - Country:US
Practice Address - Phone:616-426-2168
Practice Address - Fax:866-257-5918
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-03164101YA0400X
MI6801094413104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)