Basic Information
| Provider Information | |||||||||
| NPI: | 1548416464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., L.L.P. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 47818 VAN DYKE AVENUE | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863233620 | ||||||||
| FaxNumber: | 5863233568 | ||||||||
| Practice Location | |||||||||
| Address1: | 47818 VAN DYKE AVE | ||||||||
| Address2: | |||||||||
| City: | SHELBY TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483173373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863233620 | ||||||||
| FaxNumber: | 5863233568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 07/01/2015 | ||||||||
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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 | 103TC0700X | 6301013793 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 20576 | 01 | MI | BCBSM SUBSTANCE ABUSE | OTHER | 1705289 | 05 | MI | MEDICAID | 028363 | 01 | MI | VALUE OPTIONS | OTHER | 7509105060 | 01 | MI | BCBSM | OTHER | 5266701 | 01 | MI | AETNA | OTHER |