Provider Demographics
NPI:1770986556
Name:JOHNSON, DEREK ALAN
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ALAN
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 1:23772 WEST RD # 195
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3050
Mailing Address - Country:US
Mailing Address - Phone:734-512-9367
Mailing Address - Fax:
Practice Address - Street 1:23772 WEST RD # 195
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-3050
Practice Address - Country:US
Practice Address - Phone:734-512-9367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010980191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical