MEDICARE: DR. ELIZABETH ANN JOHNSON PH.D.

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	103T00000X	Psychologist	5806625-2501	UT

General Provider Information

NPI Number	:	1225139017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH ANN JOHNSON PH.D.

Provider Business Mailing Address
First Line	:	3090 WINDMILL CIRCLE
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765
Country	:	US
Telephone Number	:	435-673-9083
Fax Number	:

Provider Business Practice Location Address
First Line	:	3090 WINDMILL CIRCLE
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765
Country	:	US
Telephone Number	:	435-673-9083
Fax Number	:

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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