Healthcare Provider Details

I. General information

NPI: 1639367618
Provider Name (Legal Business Name): MICHELLE L JOHNSON MSW, CADC 2
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 MISSION AVE FL 3
SAN RAFAEL CA
94901-6106
US

IV. Provider business mailing address

35 THOMAS DR APT 1
MILL VALLEY CA
94941-1634
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-6964
  • Fax:
Mailing address:
  • Phone: 415-215-6542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: