Healthcare Provider Details

I. General information

NPI: 1306333893
Provider Name (Legal Business Name): AUDRA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2018
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W MAIN ST
MIDLAND MI
48640-5184
US

IV. Provider business mailing address

2276 N SMITH ST
SANFORD MI
48657-9479
US

V. Phone/Fax

Practice location:
  • Phone: 989-631-0241
  • Fax:
Mailing address:
  • Phone: 989-708-1381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012591
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: