Provider Demographics
NPI:1770820474
Name:JOHNSON, KATHRYN M (LBSW, QIDP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LBSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3353 LOUSMA DR SE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49548-2251
Mailing Address - Country:US
Mailing Address - Phone:616-241-6258
Mailing Address - Fax:616-241-6470
Practice Address - Street 1:3353 LOUSMA DR SE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49548-2251
Practice Address - Country:US
Practice Address - Phone:616-248-6258
Practice Address - Fax:616-241-6470
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085815104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802085815OtherBACHELOR OF SOCIAL WORK