Provider Demographics
NPI:1154871499
Name:JOHNSON, MARNIECE (PSYD)
Entity type:Individual
Prefix:
First Name:MARNIECE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W GLEN FLORA AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-1376
Mailing Address - Country:US
Mailing Address - Phone:708-250-4767
Mailing Address - Fax:
Practice Address - Street 1:3900 W BROWN DEER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1220
Practice Address - Country:US
Practice Address - Phone:414-540-2170
Practice Address - Fax:414-540-2171
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010726103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical