Provider Demographics
NPI:1669858478
Name:JOHNSON, DERRECK (LLPC, DP-C)
Entity Type:Individual
Prefix:
First Name:DERRECK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LLPC, DP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 S FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-1447
Mailing Address - Country:US
Mailing Address - Phone:989-792-8000
Mailing Address - Fax:989-792-8445
Practice Address - Street 1:1555 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-9775
Practice Address - Country:US
Practice Address - Phone:989-723-6791
Practice Address - Fax:989-725-5061
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6401015200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)