Healthcare Provider Details

I. General information

NPI: 1154739597
Provider Name (Legal Business Name): TRICIA NEWLAND JOHNSON L.M.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6418 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

IV. Provider business mailing address

6418 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

V. Phone/Fax

Practice location:
  • Phone: 269-815-5505
  • Fax: 269-815-5373
Mailing address:
  • Phone: 269-815-5505
  • Fax: 269-815-5373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801087610
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: