Provider Demographics
NPI:1417716374
Name:JOHNSON, STEPHAN
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2168
Mailing Address - Country:US
Mailing Address - Phone:906-228-9699
Mailing Address - Fax:888-972-2109
Practice Address - Street 1:1009 W RIDGE ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3997
Practice Address - Country:US
Practice Address - Phone:906-228-6545
Practice Address - Fax:906-228-8236
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator