Provider Demographics
NPI:1689139354
Name:JOHNSON, TIMOTHY EDWARD
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118
Mailing Address - Country:US
Mailing Address - Phone:248-372-9825
Mailing Address - Fax:
Practice Address - Street 1:1075 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118
Practice Address - Country:US
Practice Address - Phone:248-372-9825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJ525793189116103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA