MEDICARE: AUDRA JOHNSON

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	1041C0700X	Clinical Social Worker	149.025033	IL
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1124629696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDRA JOHNSON

Provider Business Mailing Address
First Line	:	PO BOX 107
Second Line	:
City	:	CORTLAND
State	:	IL
Zip	:	60112-0107
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 N MILL ST STE F
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-4872
Country	:	US
Telephone Number	:	630-536-8073
Fax Number	:

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

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	01/18/2024

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Directions to “ AUDRA JOHNSON ” Practice Location

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