MEDICARE: MS. LISA ASHELY JOHNSON MSSW

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	104100000X	Social Worker	SWC.0000001836	CO

General Provider Information

NPI Number	:	1255158119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA ASHELY JOHNSON MSSW

Provider Business Mailing Address
First Line	:	PO BOX 1211
Second Line	:
City	:	WELLINGTON
State	:	CO
Zip	:	80549-1211
Country	:	US
Telephone Number	:	970-430-6589
Fax Number	:

Provider Business Practice Location Address
First Line	:	3711 JOHN F KENNEDY PKWY
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2620
Country	:	US
Telephone Number	:	970-430-6589
Fax Number	:

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

Provider Enumeration Date	:	09/23/2024
Last Update Date	:	09/23/2024

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