Provider Demographics
NPI:1265656516
Name:JOHNSON, SANDRA K (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8200 E JEFFERSON AVE APT 1604
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-3978
Mailing Address - Country:US
Mailing Address - Phone:248-766-3209
Mailing Address - Fax:313-557-1662
Practice Address - Street 1:1001 WOODWARD AVE FL 5
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226
Practice Address - Country:US
Practice Address - Phone:313-739-7836
Practice Address - Fax:313-557-1662
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI6301006837103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301006837OtherLICENSE