Provider Demographics
NPI:1417452905
Name:JOHNSON, MICHAEL K
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PARKLANDS DR UNIT 1737
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-5193
Mailing Address - Country:US
Mailing Address - Phone:854-245-0184
Mailing Address - Fax:980-303-2682
Practice Address - Street 1:1 PROFESSIONAL DR STE 8
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1104
Practice Address - Country:US
Practice Address - Phone:854-245-0184
Practice Address - Fax:980-303-2682
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13893101YM0800X
NC13893101YM0800X
SC8612101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health