=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114005667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATHRYN JOHNSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 N HIGHWAY 19A SUITE 4
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-988-4181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5655 S ORANGE AVE
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32809-4289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-895-4100
-----------------------------------------------------
Fax | 407-422-4492
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOSOCIAL CLINICIAN II
-----------------------------------------------------
Name | MS. KATHRYN JOHNSON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 352-988-4181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------