Healthcare Provider Details

I. General information

NPI: 1184180465
Provider Name (Legal Business Name): DIANE MARIE JOHNSTON LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date: 08/16/2019
Reactivation Date: 11/13/2019

III. Provider practice location address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

IV. Provider business mailing address

2025 DUNHAM DR
ROCHESTER MI
48306-4804
US

V. Phone/Fax

Practice location:
  • Phone: 313-875-7601
  • Fax:
Mailing address:
  • Phone: 248-913-5290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401017050
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: