Provider Demographics
NPI:1851139620
Name:JOHNSON, DAMITA
Entity type:Individual
Prefix:
First Name:DAMITA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DAMITA
Other - Middle Name:
Other - Last Name:JOHNSON-EL-BEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 W FORT ST UNIT 441846
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-3575
Mailing Address - Country:US
Mailing Address - Phone:313-492-9437
Mailing Address - Fax:
Practice Address - Street 1:1401 W FORT ST UNIT 441846
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48244-3575
Practice Address - Country:US
Practice Address - Phone:313-492-9437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 372600000X, 374K00000X, 374U00000X
MIJ525135122103172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Multi-Specialty