Healthcare Provider Details

I. General information

NPI: 1306927827
Provider Name (Legal Business Name): STACIE A JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 S VAN DYKE
BAD AXE MI
48413
US

IV. Provider business mailing address

8553 WILLARD ST
MILLINGTON MI
48746
US

V. Phone/Fax

Practice location:
  • Phone: 989-269-9293
  • Fax: 989-269-7455
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801070204
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: