Provider Demographics
NPI:1184036220
Name:JOHNSON, LORRAIN
Entity Type:Individual
Prefix:
First Name:LORRAIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 E 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1962
Mailing Address - Country:US
Mailing Address - Phone:248-547-2668
Mailing Address - Fax:248-547-3062
Practice Address - Street 1:642 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1962
Practice Address - Country:US
Practice Address - Phone:248-547-2668
Practice Address - Fax:248-547-3062
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007092171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator