Provider Demographics
NPI:1467804104
Name:JOHNSON-MASTIN, MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:JOHNSON-MASTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:JOHNSON, HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:6418 DEANS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-8713
Mailing Address - Country:US
Mailing Address - Phone:269-815-5500
Mailing Address - Fax:269-815-5373
Practice Address - Street 1:6418 DEANS HILL RD
Practice Address - Street 2:
Practice Address - City:BERRIEN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49102-8713
Practice Address - Country:US
Practice Address - Phone:269-815-5500
Practice Address - Fax:269-815-5373
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI680193354103TC0700X
101YA0400X
MI6801093354104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker