Basic Information
| Provider Information | |||||||||
| NPI: | 1669858478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DERRECK | ||||||||
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| Credential: | LLPC, DP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 S FAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486021447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897928000 | ||||||||
| FaxNumber: | 9897928445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488679775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | 9897255061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 6401015200 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.