MEDICARE: DR. BENETTA E JOHNSON PHD, HSPP

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	101YM0800X	Mental Health Counselor	99034346A	IN

General Provider Information

NPI Number	:	1194977298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENETTA E JOHNSON PHD, HSPP

Provider Business Mailing Address
First Line	:	5610 CRAWFORDSVILLE RD
Second Line	:	SUITE 200
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-3714
Country	:	US
Telephone Number	:	317-241-4673
Fax Number	:	317-241-0201

Provider Business Practice Location Address
First Line	:	5610 CRAWFORDSVILLE RD
Second Line	:	SUITE 200
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-3714
Country	:	US
Telephone Number	:	317-241-4673
Fax Number	:	317-241-0201

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

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	11/15/2016

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