Provider Demographics
NPI:1659588093
Name:JOHNSON, JOSEPH S (BA, CAC 1)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BA, CAC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SYDELLE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-4339
Mailing Address - Country:US
Mailing Address - Phone:269-501-5276
Mailing Address - Fax:
Practice Address - Street 1:1020 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1166
Practice Address - Country:US
Practice Address - Phone:269-344-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)