Provider Demographics
NPI:1427256239
Name:TERRENCE J JOHNSON PH D PC
Entity type:Organization
Organization Name:TERRENCE J JOHNSON PH D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRENCE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:989-723-1120
Mailing Address - Street 1:802 W KING ST
Mailing Address - Street 2:SUITE P.
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2100
Mailing Address - Country:US
Mailing Address - Phone:989-723-1120
Mailing Address - Fax:989-729-6506
Practice Address - Street 1:802 W KING ST
Practice Address - Street 2:SUITE P.
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2100
Practice Address - Country:US
Practice Address - Phone:989-723-1120
Practice Address - Fax:989-729-6506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002288103T00000X
MI6301002671103TC0700X
MI68010191501041C0700X
MI4101005346106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G84501Medicare ID - Type Unspecified