Provider Demographics
NPI:1962787796
Name:JOHNSON, MEAGAN ELIZABETH (MS, TLLP)
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 STACY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1432
Mailing Address - Country:US
Mailing Address - Phone:734-968-1344
Mailing Address - Fax:
Practice Address - Street 1:1202 STACY DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1432
Practice Address - Country:US
Practice Address - Phone:734-968-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014816103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical