Provider Demographics
NPI:1417295890
Name:JOHNSON, CARLENE (CTRS)
Entity Type:Individual
Prefix:MISS
First Name:CARLENE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13871 BITTERSWEET DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9450
Mailing Address - Country:US
Mailing Address - Phone:616-402-7822
Mailing Address - Fax:855-207-3270
Practice Address - Street 1:13871 BITTERSWEET DR
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-9450
Practice Address - Country:US
Practice Address - Phone:616-402-7822
Practice Address - Fax:855-207-3270
Is Sole Proprietor?:No
Enumeration Date:2013-01-20
Last Update Date:2013-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist