Provider Demographics
NPI:1265033906
Name:JOHNSON, SHAUNTEZ ANIONIE (MSW)
Entity Type:Individual
Prefix:
First Name:SHAUNTEZ
Middle Name:ANIONIE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2302
Mailing Address - Country:US
Mailing Address - Phone:313-424-3513
Mailing Address - Fax:
Practice Address - Street 1:6309 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2302
Practice Address - Country:US
Practice Address - Phone:313-424-3513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851108961101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical