Provider Demographics
NPI:1790577179
Name:JOHNSON, HATTIE
Entity type:Individual
Prefix:
First Name:HATTIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17250 W 12 MILE RD STE 211A
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2123
Mailing Address - Country:US
Mailing Address - Phone:248-508-2858
Mailing Address - Fax:
Practice Address - Street 1:17250 W 12 MILE RD STE 211A
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2123
Practice Address - Country:US
Practice Address - Phone:248-508-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health