Healthcare Provider Details

I. General information

NPI: 1821087784
Provider Name (Legal Business Name): RODERICK LYNN JOHNSON M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: RODERICK LYNN JOHNSON

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W MICHIGAN AVE SUITE #3
PAW PAW MI
49079-1432
US

IV. Provider business mailing address

181 W MICHIGAN AVE SUITE #3
PAW PAW MI
49079-1432
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-6025
  • Fax: 269-657-5198
Mailing address:
  • Phone: 269-657-6025
  • Fax: 269-657-5198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301010127
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: