Healthcare Provider Details

I. General information

NPI: 1366637829
Provider Name (Legal Business Name): LISA GIFFORD JOHNSON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 03/27/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST SE STE 306
GRAND RAPIDS MI
49546-7717
US

IV. Provider business mailing address

2020 RAYBROOK ST SE STE 306
GRAND RAPIDS MI
49546-7717
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-0656
  • Fax:
Mailing address:
  • Phone: 616-901-2353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801067023
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: