Provider Demographics
NPI:1790016137
Name:JOHNSON, GLORIA MARCELLA (LLPC)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:MARCELLA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24615 LATHRUP BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2744
Mailing Address - Country:US
Mailing Address - Phone:313-283-5361
Mailing Address - Fax:
Practice Address - Street 1:21261 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3125
Practice Address - Country:US
Practice Address - Phone:586-771-7253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011563101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional