Provider Demographics
NPI:1700139904
Name:JOHNSON, DEREK EVERETT (LMSW)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:EVERETT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 MITCHELL PARK DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8674
Mailing Address - Country:US
Mailing Address - Phone:231-487-2415
Mailing Address - Fax:
Practice Address - Street 1:2206 MITCHELL PARK DR
Practice Address - Street 2:SUITE 10
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8674
Practice Address - Country:US
Practice Address - Phone:231-487-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010893961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical