Provider Demographics
NPI:1265293278
Name:JOHNSON, ELEANOR KAYE
Entity type:Individual
Prefix:
First Name:ELEANOR
Middle Name:KAYE
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 1:1 LAFAYETTE PLAISANCE ST APT 1617
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2865
Mailing Address - Country:US
Mailing Address - Phone:404-593-4494
Mailing Address - Fax:
Practice Address - Street 1:1333 BREWERY PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4544
Practice Address - Country:US
Practice Address - Phone:313-446-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802464510OtherNON PROFIT
MIJ525205461773OtherEXERCISE AND WELLNESS