Provider Demographics
NPI:1841762671
Name:JOHNSON, KATRINA MARIE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16454 WICKIE RD
Mailing Address - Street 2:
Mailing Address - City:BANNISTER
Mailing Address - State:MI
Mailing Address - Zip Code:48807-9302
Mailing Address - Country:US
Mailing Address - Phone:989-640-8521
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-253-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1073588711Medicaid