Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 106S00000X | Behavior Technician | ||
Y | 156FC0800X | Contact Lens |
NPI | 1780258384 |
---|---|
Provider Name | Serenity Johnson |
First Address | Grosse Pointe Woods, MI 48236-2893 |
Second Address | Grosse Pointe Woods, MI 48236-2893 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2021 |
Last Update Date | 10/01/2022 |