Provider Demographics
NPI:1366637829
Name:JOHNSON, LISA GIFFORD (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GIFFORD
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 RAYBROOK ST SE STE 306
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7717
Mailing Address - Country:US
Mailing Address - Phone:616-901-2353
Mailing Address - Fax:
Practice Address - Street 1:2020 RAYBROOK ST SE STE 306
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7717
Practice Address - Country:US
Practice Address - Phone:616-949-0656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010670231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008931390OtherBCBS OF MI
MION49970Medicare PIN