MEDICARE: KATHRYN 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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SW 6550	OTHER	FL	SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1114005667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHRYN JOHNSON

Provider Business Mailing Address
First Line	:	5655 S ORANGE AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-4289
Country	:	US
Telephone Number	:	407-895-4100
Fax Number	:	407-422-4492

Provider Business Practice Location Address
First Line	:	4400 N HIGHWAY 19A
Second Line	:	SUITE 4
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-2032
Country	:	US
Telephone Number	:	352-988-4181
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOSOCIAL CLINICIAN II
Name	:	MS. KATHRYN JOHNSON
Credential	:	LCSW
Telephone Number	:	352-988-4181

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2020

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Directions to “KATHRYN JOHNSON ” Practice Location

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