Provider Demographics
NPI:1215267257
Name:JOHNSON, MARCIA ELENA (PSYD)
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:ELENA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:ATTN:MRMC FAMILY MEDICINE RESIDENCY PROGRAM
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-5620
Mailing Address - Fax:
Practice Address - Street 1:G3230 BEECHER RD
Practice Address - Street 2:SUITE 1
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3604
Practice Address - Country:US
Practice Address - Phone:810-342-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013972103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist