=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609164755
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VERNON KEITH JOHNSON LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2011
-----------------------------------------------------
Last Update Date | 07/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20203 KELLY ROAD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-245-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24671 PEMBROOKE DR
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-3159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-245-7000
-----------------------------------------------------
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 | 6801066866
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------