Provider Demographics
NPI:1780400259
Name:JOHNSON, RAPHAEL DAVID (MA, LLC)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MA, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9234
Mailing Address - Country:US
Mailing Address - Phone:269-409-3000
Mailing Address - Fax:
Practice Address - Street 1:6070 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9234
Practice Address - Country:US
Practice Address - Phone:269-409-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024063101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health