MEDICARE: TANISHA JOHNSON M.A. R, MDIV.

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	101YP1600X	Pastoral Counselor
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1073916870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANISHA JOHNSON M.A. R, MDIV.

Provider Business Mailing Address
First Line	:	110 WOODSIDE RD
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834-1129
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 WOODSIDE RD
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27834-1129
Country	:	US
Telephone Number	:	252-302-0700
Fax Number	:

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

Provider Enumeration Date	:	10/07/2014
Last Update Date	:	10/16/2014

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