Provider Demographics
NPI:1558732586
Name:JOHNSON, GREGORY SAMUEL (LMSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SAMUEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4825
Mailing Address - Country:US
Mailing Address - Phone:313-396-5300
Mailing Address - Fax:313-396-5353
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-912-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010987901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247200000XMedicaid