MEDICARE: VALERIE JOHNSON BGS, LCDC, ADC III,

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	10074	TX

General Provider Information

NPI Number	:	1225416399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VALERIE JOHNSON BGS, LCDC, ADC III,

Provider Business Mailing Address
First Line	:	1313 OAK GROVE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-1632
Country	:	US
Telephone Number	:	817-921-2272
Fax Number	:	817-921-2272

Provider Business Practice Location Address
First Line	:	1313 OAK GROVE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-1632
Country	:	US
Telephone Number	:	817-921-2272
Fax Number	:	817-921-2272

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

Provider Enumeration Date	:	05/11/2015
Last Update Date	:	05/11/2015

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