Provider Demographics
NPI:1902639305
Name:JOHNSON, MICHELLE GABRIELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GABRIELLE
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:BERKELEY MENTAL HEALTH CENTER
Mailing Address - Street 2:403 STONY LANDING RD
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461
Mailing Address - Country:US
Mailing Address - Phone:843-761-8282
Mailing Address - Fax:843-761-7308
Practice Address - Street 1:BERKELEY MENTAL HEALTH CENTER
Practice Address - Street 2:403 STONY LANDING RD
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-761-8282
Practice Address - Fax:843-761-7308
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC435201Medicaid