Provider Demographics
NPI:1740765783
Name:JOHNSON, GENINICE (BA, LCDC-I)
Entity Type:Individual
Prefix:MS
First Name:GENINICE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA, LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ROLLING HILLS PL APT 1211
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1042
Mailing Address - Country:US
Mailing Address - Phone:313-467-6585
Mailing Address - Fax:
Practice Address - Street 1:500 ROLLING HILLS PL APT 1211
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1042
Practice Address - Country:US
Practice Address - Phone:313-467-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty