Provider Demographics
NPI:1215054952
Name:JOHNSON, STEVEN T (PHD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16165 RANSOM ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-5531
Mailing Address - Country:US
Mailing Address - Phone:616-994-6030
Mailing Address - Fax:616-994-6030
Practice Address - Street 1:493 CENTURY LN
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4286
Practice Address - Country:US
Practice Address - Phone:616-355-7190
Practice Address - Fax:616-355-9820
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007340103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11279613OtherCAQH PROVIDER ID
MI11279613OtherCAQH PROVIDER ID