MEDICARE: BEVELYN JOYCE JOHNSON MSW

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	1041C0700X	Clinical Social Worker	3754-123	WI

General Provider Information

NPI Number	:	1275756454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVELYN JOYCE JOHNSON MSW

Provider Business Mailing Address
First Line	:	5401 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-2746
Country	:	US
Telephone Number	:	414-536-1301
Fax Number	:	414-536-1568

Provider Business Practice Location Address
First Line	:	5401 N 76TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-2746
Country	:	US
Telephone Number	:	414-536-1301
Fax Number	:	414-536-1568

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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