Provider Demographics
NPI:1841729746
Name:JOHNSON, EVYNN MARIA (LMSW, LCSW)
Entity type:Individual
Prefix:
First Name:EVYNN
Middle Name:MARIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3995 STAMFORD DR
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49441-5037
Mailing Address - Country:US
Mailing Address - Phone:231-206-3686
Mailing Address - Fax:
Practice Address - Street 1:2033 KOLO RD
Practice Address - Street 2:
Practice Address - City:KILAUEA
Practice Address - State:HI
Practice Address - Zip Code:96754-5563
Practice Address - Country:US
Practice Address - Phone:231-206-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010942371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical