Healthcare Provider Details

I. General information

NPI: 1114005667
Provider Name (Legal Business Name): KATHRYN JOHNSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 N HIGHWAY 19A SUITE 4
MOUNT DORA FL
32757-2032
US

IV. Provider business mailing address

5655 S ORANGE AVE
ORLANDO FL
32809-4289
US

V. Phone/Fax

Practice location:
  • Phone: 352-988-4181
  • Fax:
Mailing address:
  • Phone: 407-895-4100
  • Fax: 407-422-4492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHRYN JOHNSON
Title or Position: PSYCHOSOCIAL CLINICIAN II
Credential: LCSW
Phone: 352-988-4181