Basic Information
| Provider Information | |||||||||
| NPI: | 1467804104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON-MASTIN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON, HART | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6418 DEANS HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERRIEN CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491028713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2698155500 | ||||||||
| FaxNumber: | 2698155373 | ||||||||
| Practice Location | |||||||||
| Address1: | 6418 DEANS HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERRIEN CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491028713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2698155500 | ||||||||
| FaxNumber: | 2698155373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 07/13/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 680193354 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 6801093354 | MI | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.