MEDICARE: DONNA JOHNSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	0204	GA

General Provider Information

NPI Number	:	1073142014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA JOHNSON

Provider Business Mailing Address
First Line	:	475 E MAIN ST STE 110
Second Line	:
City	:	CARTERSVILLE
State	:	GA
Zip	:	30121-3353
Country	:	US
Telephone Number	:	770-714-7605
Fax Number	:

Provider Business Practice Location Address
First Line	:	2644 30TH ST
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-3060
Country	:	US
Telephone Number	:	770-714-7605
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2020
Last Update Date	:	04/02/2020

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