Provider Demographics
NPI:1609677905
Name:JOHNSON, MYCHAEL GABRIELLE
Entity type:Individual
Prefix:
First Name:MYCHAEL
Middle Name:GABRIELLE
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 RECOVERY RD STE 257
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-4874
Mailing Address - Country:US
Mailing Address - Phone:615-781-4430
Mailing Address - Fax:
Practice Address - Street 1:510 RECOVERY RD STE 257
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-4874
Practice Address - Country:US
Practice Address - Phone:615-781-4430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-22
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program