Provider Demographics
NPI:1609621085
Name:JOHNSON, DEMARCO SHAUNTEZ
Entity Type:Individual
Prefix:
First Name:DEMARCO
Middle Name:SHAUNTEZ
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17499 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1266
Mailing Address - Country:US
Mailing Address - Phone:131-352-3555
Mailing Address - Fax:
Practice Address - Street 1:279 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3364
Practice Address - Country:US
Practice Address - Phone:248-745-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator