Provider Demographics
NPI:1912370024
Name:JOHNSON, DIANE (MASTERS OF SCIENCE)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MASTERS OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29327 DEBBIE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-3920
Mailing Address - Country:US
Mailing Address - Phone:619-930-0413
Mailing Address - Fax:
Practice Address - Street 1:245 PITKIN ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3737
Practice Address - Country:US
Practice Address - Phone:313-865-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)