Provider Demographics
NPI:1316163314
Name:JOHNSON, MICHELLE (BA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 NEGLEY AVE # B
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-3434
Mailing Address - Country:US
Mailing Address - Phone:812-760-0140
Mailing Address - Fax:
Practice Address - Street 1:1510 W FRANKLIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1032
Practice Address - Country:US
Practice Address - Phone:812-424-0223
Practice Address - Fax:812-424-0226
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)