Provider Demographics
NPI:1235375031
Name:JOHNSON, ANGELA NICHOELE (LLPC, LBSW)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:NICHOELE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LLPC, LBSW
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:MUCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:413 N GRAND ST STE C
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-9203
Mailing Address - Country:US
Mailing Address - Phone:269-858-8722
Mailing Address - Fax:
Practice Address - Street 1:677A EAST MAIN
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020764321041C0700X
MI6401006332101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid