Provider Demographics
NPI:1972283919
Name:JOHNSON, ROGER K (LPC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17384 BEAVERLAND ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3154
Mailing Address - Country:US
Mailing Address - Phone:313-578-1148
Mailing Address - Fax:
Practice Address - Street 1:17384 BEAVERLAND ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3154
Practice Address - Country:US
Practice Address - Phone:313-578-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401020284101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional