Basic Information
| Provider Information | |||||||||
| NPI: | 1912411273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CHANEL | ||||||||
| MiddleName: | GEORGETTE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1463 BEACONSFIELD AVE APT 2N | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482301087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863595269 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44899 CENTRE CT STE 101 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867921654 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2017 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401016390 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | 6401018436 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.