Provider Demographics
NPI:1780004028
Name:JOHNSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:ANTHONY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC,HABCP,ICADC
Mailing Address - Street 1:84 S SEAWAY DR
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3841
Mailing Address - Country:US
Mailing Address - Phone:231-733-9800
Mailing Address - Fax:231-733-1949
Practice Address - Street 1:84 S SEAWAY DR
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3841
Practice Address - Country:US
Practice Address - Phone:231-733-9800
Practice Address - Fax:231-733-1949
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01004101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI06-1756075Medicaid