Healthcare Provider Details

I. General information

NPI: 1427256239
Provider Name (Legal Business Name): TERRENCE J JOHNSON PH D PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 W KING ST SUITE P.
OWOSSO MI
48867-2100
US

IV. Provider business mailing address

802 W KING ST SUITE P.
OWOSSO MI
48867-2100
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-1120
  • Fax: 989-729-6506
Mailing address:
  • Phone: 989-723-1120
  • Fax: 989-729-6506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301002288
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301002671
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801019150
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101005346
License Number StateMI

VIII. Authorized Official

Name: DR. TERRENCE JOSEPH JOHNSON
Title or Position: PRESIDENT
Credential: PH D
Phone: 989-723-1120