Provider Demographics
NPI:1467274654
Name:JOHNSON, AMANDA C (MA, CLA, CHW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, CLA, CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15002 ASHTON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2349
Mailing Address - Country:US
Mailing Address - Phone:313-915-7633
Mailing Address - Fax:
Practice Address - Street 1:15002 ASHTON RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2349
Practice Address - Country:US
Practice Address - Phone:313-915-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI342172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker