Provider Demographics
NPI:1346954393
Name:JOHNSON, TINIECE MICHELLE
Entity Type:Individual
Prefix:
First Name:TINIECE
Middle Name:MICHELLE
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 1:52567 MARY MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-3717
Mailing Address - Country:US
Mailing Address - Phone:313-520-7905
Mailing Address - Fax:
Practice Address - Street 1:52567 MARY MARTIN DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3717
Practice Address - Country:US
Practice Address - Phone:313-520-7905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011086401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical