Provider Demographics
NPI:1750472585
Name:JOHNSON, PAMELA LYNN (LLPC)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:MISS
Other - First Name:PAMELA
Other - Middle Name:LYNN
Other - Last Name:BLUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:230 MILITARY ST.
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-987-1753
Mailing Address - Fax:810-987-1755
Practice Address - Street 1:230 MILITARY ST.
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-987-1753
Practice Address - Fax:810-987-1755
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802058909104100000X
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health