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General NPI Number Information
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NPI Number | 1225305931
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Entity Type | Individual
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Provider Name | KENNETH LORENZO JOHNSON MA, PH.D., MLP
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Gender | Male
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 13101 ALLEN RD
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City | SOUTHGATE
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State | MI
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Zip | 48195-2216
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Country | US
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Telephone | 734-785-7700
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Fax |
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Provider Business Mailing Address
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Address Line | 7605 W 7 MILE RD
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City | DETROIT
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State | MI
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Zip | 48221-2163
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 6361001548
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License Number State | MI
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