Basic Information
| Provider Information | |||||||||
| NPI: | 1255465258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | GERARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | LPC, SPADA, CAAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162816363 | ||||||||
| FaxNumber: | 6164555460 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162816363 | ||||||||
| FaxNumber: | 6164555460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 08/30/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C-01218 | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 6401008579 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | NCFR | 01 | CERTIFIED FAMILY LIFE EDUCATOR CFLE- NATIONAL COUNSEL ON FAMILY RELATIONS | OTHER | C-012118 CAAC | 01 | MI | CERTIFIED ADVANCED ADDICTION COUNSELOR | OTHER | 6401008579 | 01 | MI | PROFESSIONAL COUNSELOR | OTHER |