Provider Demographics
NPI:1821087784
Name:JOHNSON, RODERICK LYNN (MA)
Entity Type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:RODERICK
Other - Middle Name:LYNN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:181 W MICHIGAN AVE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1432
Mailing Address - Country:US
Mailing Address - Phone:269-657-6025
Mailing Address - Fax:269-657-5198
Practice Address - Street 1:181 W MICHIGAN AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1432
Practice Address - Country:US
Practice Address - Phone:269-657-6025
Practice Address - Fax:269-657-5198
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist