MEDICARE: DR. GWEN A JOHNSON PH.D., BCBA, LBA

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	103K00000X	Behavior Analyst	1-05-2208	FL

General Provider Information

NPI Number	:	1093982480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWEN A JOHNSON PH.D., BCBA, LBA

Provider Business Mailing Address
First Line	:	5980 S DURANGO DR STE 131
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-1775
Country	:	US
Telephone Number	:	614-783-4936
Fax Number	:

Provider Business Practice Location Address
First Line	:	8043 CORPORATE CIR STE 1
Second Line	:
City	:	NORTH ROYALTON
State	:	OH
Zip	:	44133-1279
Country	:	US
Telephone Number	:	614-783-4936
Fax Number	:

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

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	06/10/2021

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