Provider Demographics
NPI:1326101536
Name:JOHNSON, MARY JO (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48658 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8675
Mailing Address - Country:US
Mailing Address - Phone:248-924-2056
Mailing Address - Fax:
Practice Address - Street 1:6223 N CANTON CENTER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2696
Practice Address - Country:US
Practice Address - Phone:734-737-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010797351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical