Provider Demographics
NPI:1497023832
Name:JOHNSON, DIANNA LEE (LMSW)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10656 S TIMBERLEE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8427
Mailing Address - Country:US
Mailing Address - Phone:231-883-3085
Mailing Address - Fax:
Practice Address - Street 1:3180 RACQUET CLUB DR STE G
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4797
Practice Address - Country:US
Practice Address - Phone:231-933-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010948081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical