MEDICARE: TAMMY JON FROST JOHNSON LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	302339	MN

General Provider Information

NPI Number	:	1184899270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY JON FROST JOHNSON LADC

Provider Business Mailing Address
First Line	:	1405 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9301
Country	:	US
Telephone Number	:	651-633-4532
Fax Number	:	651-633-9311

Provider Business Practice Location Address
First Line	:	1405 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9301
Country	:	US
Telephone Number	:	651-633-4532
Fax Number	:	651-633-9311

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

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/29/2008

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