Healthcare Provider Details

I. General information

NPI: 1033743091
Provider Name (Legal Business Name): BRUCE M JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32715 DORSEY ST
WESTLAND MI
48186-4755
US

IV. Provider business mailing address

3075 E GRAND RIVER AVE STE 108
HOWELL MI
48843-6585
US

V. Phone/Fax

Practice location:
  • Phone: 734-641-1141
  • Fax:
Mailing address:
  • Phone: 248-912-2359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401223542
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: