Healthcare Provider Details

I. General information

NPI: 1124373352
Provider Name (Legal Business Name): COURTNEY J JOHNSON LMSW, CAADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 OLD 28TH ST SE STE A
GRAND RAPIDS MI
49546-6937
US

IV. Provider business mailing address

1619 GILCREST AVE
EAST LANSING MI
48823-1843
US

V. Phone/Fax

Practice location:
  • Phone: 616-426-2168
  • Fax: 866-257-5918
Mailing address:
  • Phone: 906-236-0569
  • Fax: 866-257-5918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-03164
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801094413
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: