Basic Information
| Provider Information | |||||||||
| NPI: | 1326101536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARY JO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48658 STONERIDGE DR | ||||||||
| Address2: | |||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481688675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489242056 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6223 N CANTON CENTER RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481872696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347371200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801079735 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.