Healthcare Provider Details

I. General information

NPI: 1326361130
Provider Name (Legal Business Name): LANA B. JOHNSON MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LANA B. ELLIS

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10761 RIVERSIDE DR
WHITE PIGEON MI
49099-9191
US

IV. Provider business mailing address

10761 RIVERSIDE DR
WHITE PIGEON MI
49099-9191
US

V. Phone/Fax

Practice location:
  • Phone: 574-400-5724
  • Fax: 574-293-0019
Mailing address:
  • Phone: 574-400-5724
  • Fax: 574-293-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33005821A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006584A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: