Healthcare Provider Details

I. General information

NPI: 1821684903
Provider Name (Legal Business Name): KAELYN PAIGE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34841 VETERANS PLAZA
WAYNE MI
48184-1733
US

IV. Provider business mailing address

34841 VETERANS PLAZA
WAYNE MI
48184-1733
US

V. Phone/Fax

Practice location:
  • Phone: 313-292-7640
  • Fax: 313-292-9270
Mailing address:
  • Phone: 313-292-7640
  • Fax: 313-292-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801108423
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: