Provider Demographics
NPI:1629637491
Name:JOHNSON, SHUNA
Entity Type:Individual
Prefix:
First Name:SHUNA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48502-1620
Mailing Address - Country:US
Mailing Address - Phone:810-232-6081
Mailing Address - Fax:810-232-6510
Practice Address - Street 1:929 STEVENS ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1620
Practice Address - Country:US
Practice Address - Phone:810-232-6081
Practice Address - Fax:810-232-6510
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Medicaid
MI05Medicaid