Provider Demographics
NPI:1053968388
Name:PHILLIPS, JOHANNA LEE (LMSW)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:LEE
Other - Last Name:PHILLIPS CARPENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1209 N CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-4603
Mailing Address - Country:US
Mailing Address - Phone:734-480-8322
Mailing Address - Fax:
Practice Address - Street 1:2311 E STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4833
Practice Address - Country:US
Practice Address - Phone:734-480-8322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011936961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty