Provider Demographics
NPI:1639743230
Name:JOHNSON, LOLETA
Entity Type:Individual
Prefix:
First Name:LOLETA
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 1:29501 GREENFIELD RD STE 132
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2250
Mailing Address - Country:US
Mailing Address - Phone:248-469-8141
Mailing Address - Fax:
Practice Address - Street 1:29501 GREENFIELD RD STE 132
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2250
Practice Address - Country:US
Practice Address - Phone:248-207-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty