Provider Demographics
NPI:1700593084
Name:JOHNSON, MICHAEL C
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9287 S AVIGNON PL
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9067
Mailing Address - Country:US
Mailing Address - Phone:801-618-6756
Mailing Address - Fax:
Practice Address - Street 1:9287 S AVIGNON PL
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9067
Practice Address - Country:US
Practice Address - Phone:801-618-6756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTA10097745Medicaid