MEDICARE: ELIZABETH JOHNSON, PHD., LLC

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1013542034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELIZABETH JOHNSON, PHD., LLC

Provider Business Mailing Address
First Line	:	4860 ROBB ST STE 201
Second Line	:
City	:	WHEAT RIDGE
State	:	CO
Zip	:	80033-2162
Country	:	US
Telephone Number	:	888-948-6789
Fax Number	:	877-345-3501

Provider Business Practice Location Address
First Line	:	2612 W CUCHARRAS ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-3031
Country	:	US
Telephone Number	:	888-948-6789
Fax Number	:	877-345-3501

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH A JOHNSON
Credential	:	PHD
Telephone Number	:	307-286-2851

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	03/10/2020

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