Provider Demographics
NPI:1649387408
Name:JOHNSON, SANDRA JEAN (MSW)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 CHELTINGHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-5151
Mailing Address - Country:US
Mailing Address - Phone:517-285-8775
Mailing Address - Fax:517-323-7524
Practice Address - Street 1:601 N WAVERLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2851
Practice Address - Country:US
Practice Address - Phone:517-285-8775
Practice Address - Fax:517-323-7524
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL9032781041C0700X
MIL833192106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0890342Medicare UPIN