Healthcare Provider Details

I. General information

NPI: 1285284794
Provider Name (Legal Business Name): DETROIT HEALTH & WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WOODWARD AVE FL 5
DETROIT MI
48226-1904
US

IV. Provider business mailing address

8200 E JEFFERSON AVE APT 1604
DETROIT MI
48214-3978
US

V. Phone/Fax

Practice location:
  • Phone: 313-739-7836
  • Fax: 313-557-1662
Mailing address:
  • Phone: 248-766-3209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SANDRA KRISTINE JOHNSON
Title or Position: CLINICAL DIRECTOR
Credential: PH.D.
Phone: 248-766-3209