Healthcare Provider Details

I. General information

NPI: 1669988283
Provider Name (Legal Business Name): CARLA SUE HURST-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13340 E WARREN AVE
DETROIT MI
48215-2112
US

IV. Provider business mailing address

13725 LASALLE BLVD APT 211
DETROIT MI
48238
US

V. Phone/Fax

Practice location:
  • Phone: 313-822-6940
  • Fax: 313-822-6946
Mailing address:
  • Phone: 313-412-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: