MEDICARE: DR. VELISA MARIE JOHNSON PHD, ABPP-CN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	6301016552	MI
2	103T00000X	Psychologist
3	103G00000X	Clinical Neuropsychologist	36373	CA
4	103G00000X	Clinical Neuropsychologist	PSY-2300-0	HI

General Provider Information

NPI Number	:	1184892952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VELISA MARIE JOHNSON PHD, ABPP-CN

Provider Business Mailing Address
First Line	:	5030 CORPORATE EXCHANGE BLVD SE STE 201
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5506
Country	:	US
Telephone Number	:	616-287-4164
Fax Number	:	616-419-8412

Provider Business Practice Location Address
First Line	:	5030 CORPORATE EXCHANGE BLVD SE STE 201
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49512-5506
Country	:	US
Telephone Number	:	616-287-4164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2008
Last Update Date	:	02/02/2026

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