Provider Demographics
NPI:1639436173
Name:JOHNSON, THOMAS EDGAR (LMSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EDGAR
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 1:9351 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:MI
Mailing Address - Zip Code:48191-9725
Mailing Address - Country:US
Mailing Address - Phone:734-461-6447
Mailing Address - Fax:
Practice Address - Street 1:19366 ALLEN RD STE C
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-6810
Practice Address - Country:US
Practice Address - Phone:734-479-0949
Practice Address - Fax:734-479-1637
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010111641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical