Provider Demographics
NPI:1740797844
Name:JOHNSON, CALLI LYNN (LLP)
Entity Type:Individual
Prefix:
First Name:CALLI
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49346-0338
Mailing Address - Country:US
Mailing Address - Phone:231-250-0965
Mailing Address - Fax:
Practice Address - Street 1:7302 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:MI
Practice Address - Zip Code:49346-8742
Practice Address - Country:US
Practice Address - Phone:231-823-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007717103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical