Provider Demographics
NPI:1396012928
Name:JOHNSON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:SEARS
Mailing Address - State:MI
Mailing Address - Zip Code:49679-0458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5750 40TH AVE
Practice Address - Street 2:
Practice Address - City:SEARS
Practice Address - State:MI
Practice Address - Zip Code:49679-7003
Practice Address - Country:US
Practice Address - Phone:231-734-0513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker