Provider Demographics
NPI:1255465258
Name:JOHNSON, ROBERT GERARD SR (LPC, SPADA, CAAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GERARD
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:LPC, SPADA, CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-281-6363
Mailing Address - Fax:616-455-5460
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-281-6363
Practice Address - Fax:616-455-5460
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-01218101YA0400X
MI6401008579101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFROtherCERTIFIED FAMILY LIFE EDUCATOR CFLE- NATIONAL COUNSEL ON FAMILY RELATIONS
MIC-012118 CAACOtherCERTIFIED ADVANCED ADDICTION COUNSELOR
MI6401008579OtherPROFESSIONAL COUNSELOR