MEDICARE: MS. SUSAN DIANNE JOHNSON LCSW

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	1041C0700X	Clinical Social Worker	LCSW-689	WY

General Provider Information

NPI Number	:	1770607426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN DIANNE JOHNSON LCSW

Provider Business Mailing Address
First Line	:	103 N 5TH ST E
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-4402
Country	:	US
Telephone Number	:	307-463-0890
Fax Number	:	307-463-0891

Provider Business Practice Location Address
First Line	:	103 N 5TH ST E
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-4402
Country	:	US
Telephone Number	:	307-463-0890
Fax Number	:	307-463-0891

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/21/2022

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