Provider Demographics
NPI:1093853863
Name:JOHNSON, LINDA ANN (LCSW, LMSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:ANN
Other - Last Name:RISSELADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:17325 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-847-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC122011041C0700X
MI68010661381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME435265199Medicaid
LJ066138OtherBCBS
ME435265199Medicaid
MEE400171649Medicare PIN