Provider Demographics
NPI:1982292280
Name:JOHNSON, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
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 1:1930 LAURIA RD
Mailing Address - Street 2:
Mailing Address - City:KAWKAWLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48631-9159
Mailing Address - Country:US
Mailing Address - Phone:989-415-6573
Mailing Address - Fax:
Practice Address - Street 1:3258 RINGLE RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:MI
Practice Address - Zip Code:48701-9519
Practice Address - Country:US
Practice Address - Phone:989-737-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician