Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 6301009715 | MI |
NPI | 1043372634 |
---|---|
Provider Name | Leslie Johnsen |
First Address | Troy, MI 48084-4762 |
Second Address | Troy, MI 48084-4762 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 03/06/2021 |