MEDICARE: EVAN JOHNSON MSW, LCSW

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	11000-123	WI

General Provider Information

NPI Number	:	1134812043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN JOHNSON MSW, LCSW

Provider Business Mailing Address
First Line	:	2536 S 67TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-2635
Country	:	US
Telephone Number	:	414-721-1574
Fax Number	:

Provider Business Practice Location Address
First Line	:	1429 N PROSPECT AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3017
Country	:	US
Telephone Number	:	414-721-1574
Fax Number	:

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

Provider Enumeration Date	:	05/29/2023
Last Update Date	:	05/29/2023

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