Provider Demographics
NPI:1497104202
Name:JOHNSON, MICHAEL DWIGHT (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DWIGHT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14909 LEJUENE LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1519
Mailing Address - Country:US
Mailing Address - Phone:813-545-8537
Mailing Address - Fax:
Practice Address - Street 1:4422 E COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-3233
Practice Address - Country:US
Practice Address - Phone:813-635-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2796106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060650200Medicaid