Provider Demographics
NPI:1134660418
Name:JOHNSON, DESIREE (LLMSW)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25431 PEMBROKE AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1044
Mailing Address - Country:US
Mailing Address - Phone:313-318-6255
Mailing Address - Fax:
Practice Address - Street 1:24209 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 258
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2539
Practice Address - Country:US
Practice Address - Phone:313-444-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096786104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker