Provider Demographics
NPI:1194069245
Name:JOHNSON, LATINA MARIE (MBA)
Entity type:Individual
Prefix:MS
First Name:LATINA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29192 ALINE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2691
Mailing Address - Country:US
Mailing Address - Phone:313-286-1926
Mailing Address - Fax:
Practice Address - Street 1:29192 ALINE DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2691
Practice Address - Country:US
Practice Address - Phone:313-286-1926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)