Individual
DWAYNE ANTHONY JOHNSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1115 BALL AVE NE BLDG A, GRAND RAPIDS, MI 49505-5904
(616) 456-7775
Mailing address
1115 BALL AVE NE BLDG A, GRAND RAPIDS, MI 49505-5904
(616) 456-7775
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
J525157067197
DRIVERS LICENSE NUMBER
MI
Enumeration date
08/24/2018
Last updated
08/24/2018
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