=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497023832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNA LEE JOHNSON LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2011
-----------------------------------------------------
Last Update Date | 01/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3180 RACQUET CLUB DR STE G
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-4797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-933-4009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10656 S TIMBERLEE DR
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-8427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-883-3085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801094808
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------