Healthcare Provider Details

I. General information

NPI: 1154871499
Provider Name (Legal Business Name): MARNIECE JOHNSON PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 W BROWN DEER RD SUITE 200
BROWN DEER WI
53209-1220
US

IV. Provider business mailing address

2801 W GLEN FLORA AVE APT 207
WAUKEGAN IL
60085-1376
US

V. Phone/Fax

Practice location:
  • Phone: 414-540-2170
  • Fax: 414-540-2171
Mailing address:
  • Phone: 708-250-4767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.010726
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: