MEDICARE: RICHARD 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	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1275936197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD JOHNSON

Provider Business Mailing Address
First Line	:	7606 PARKER ST
Second Line	:	FORT RILEY
City	:	JUNCTION CITY
State	:	KS
Zip	:	66442-4247
Country	:	US
Telephone Number	:	785-240-5814
Fax Number	:

Provider Business Practice Location Address
First Line	:	7606 PARKER ST
Second Line	:	FORT RILEY
City	:	JUNCTION CITY
State	:	KS
Zip	:	66442-4247
Country	:	US
Telephone Number	:	785-240-5814
Fax Number	:

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

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	10/06/2014

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