Provider Demographics
NPI:1255926143
Name:JOHNSON, TOMMIE EARL (LLMSW)
Entity type:Individual
Prefix:MR
First Name:TOMMIE
Middle Name:EARL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3584 FAIRLANES AVE SW STE 2
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1583
Mailing Address - Country:US
Mailing Address - Phone:616-222-5300
Mailing Address - Fax:
Practice Address - Street 1:3584 FAIRLANES AVE SW STE 2
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1583
Practice Address - Country:US
Practice Address - Phone:616-222-5300
Practice Address - Fax:616-531-0447
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X
MI680115877405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention Professional
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty