Provider Demographics
NPI:1497794002
Name:JOHNSON, BETTIE S (CSW)
Entity Type:Individual
Prefix:
First Name:BETTIE
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 CONCORD ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-3183
Mailing Address - Country:US
Mailing Address - Phone:810-232-8692
Mailing Address - Fax:
Practice Address - Street 1:303 W WATER ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5627
Practice Address - Country:US
Practice Address - Phone:810-213-0015
Practice Address - Fax:810-213-0311
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801082074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
N47400010Medicare UPIN