MEDICARE: LOWANDA LEE JOHNSON

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	103TM1800X	Intellectual & Developmental Disabilities Psychologist

General Provider Information

NPI Number	:	1245039254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOWANDA LEE JOHNSON

Provider Business Mailing Address
First Line	:	9508 KEMPTON AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2943
Country	:	US
Telephone Number	:	216-490-9482
Fax Number	:

Provider Business Practice Location Address
First Line	:	9508 KEMPTON AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2943
Country	:	US
Telephone Number	:	216-490-9482
Fax Number	:

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

Provider Enumeration Date	:	03/11/2025
Last Update Date	:	03/11/2025

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