MEDICARE: DR. KATHLEEN SHUCK JOHNSON M.D.

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	2084P0800X	Psychiatry Physician	93-291	NM

General Provider Information

NPI Number	:	1952356180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHLEEN SHUCK JOHNSON M.D.

Provider Business Mailing Address
First Line	:	4115 MONTGOMERY BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-1102
Country	:	US
Telephone Number	:	505-881-0092
Fax Number	:

Provider Business Practice Location Address
First Line	:	4115 MONTGOMERY BLVD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-1102
Country	:	US
Telephone Number	:	505-881-0092
Fax Number	:

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

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	09/06/2007

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