MEDICARE: WESLEY DAVID JOHNSON CCDC II

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	08051365	SD

General Provider Information

NPI Number	:	1396012514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WESLEY DAVID JOHNSON CCDC II

Provider Business Mailing Address
First Line	:	809 SOUTH ST STE 208
Second Line	:
City	:	RAPID CITY
State	:	NJ
Zip	:	57701
Country	:	US
Telephone Number	:	605-391-3482
Fax Number	:	605-342-8144

Provider Business Practice Location Address
First Line	:	809 SOUTH ST STE 208
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-3583
Country	:	US
Telephone Number	:	605-391-3482
Fax Number	:	605-342-8144

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

Provider Enumeration Date	:	11/17/2011
Last Update Date	:	11/17/2011

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