Provider Demographics
NPI:1174140388
Name:JOHNSON, CARIN LEA
Entity type:Individual
Prefix:
First Name:CARIN
Middle Name:LEA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARIN
Other - Middle Name:
Other - Last Name:OBERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9384 W H AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8587
Mailing Address - Country:US
Mailing Address - Phone:269-254-3701
Mailing Address - Fax:
Practice Address - Street 1:8080 MOORSBRIDGE RD STE 102
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4422
Practice Address - Country:US
Practice Address - Phone:269-254-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801106922104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker