Provider Demographics
NPI:1194159483
Name:JOHNSON, CHARLA GRACE (LMSW)
Entity type:Individual
Prefix:MS
First Name:CHARLA
Middle Name:GRACE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 EVELYN AVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-6463
Mailing Address - Country:US
Mailing Address - Phone:734-347-7144
Mailing Address - Fax:
Practice Address - Street 1:6276 JACKSON RD STE D
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9579
Practice Address - Country:US
Practice Address - Phone:734-956-0051
Practice Address - Fax:888-976-6019
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010917891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical