Provider Demographics
NPI:1740952167
Name:JOHNSON, MIA C
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:C
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1406
Mailing Address - Country:US
Mailing Address - Phone:260-421-5000
Mailing Address - Fax:260-421-5003
Practice Address - Street 1:375 W 84TH DR
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6245
Practice Address - Country:US
Practice Address - Phone:260-421-5000
Practice Address - Fax:260-421-5003
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004056A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health