Provider Demographics
NPI:1689345720
Name:JOHNSON, AGGIE REBECCA-MARIA (LLMSW)
Entity Type:Individual
Prefix:
First Name:AGGIE
Middle Name:REBECCA-MARIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14616 STAHELIN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-3604
Mailing Address - Country:US
Mailing Address - Phone:734-405-9092
Mailing Address - Fax:
Practice Address - Street 1:21 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-5613
Practice Address - Country:US
Practice Address - Phone:586-840-8614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511096731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty