Provider Demographics
NPI:1790310886
Name:JOHNSON, LATRELL LATRESS (LLBSW)
Entity Type:Individual
Prefix:
First Name:LATRELL
Middle Name:LATRESS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26875 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-7556
Mailing Address - Country:US
Mailing Address - Phone:313-465-5307
Mailing Address - Fax:
Practice Address - Street 1:35425 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-9800
Practice Address - Country:US
Practice Address - Phone:734-722-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802089266171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator