MEDICARE: MRS. DIANE MARIE JOHNSON MS, LPC, NCC

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	101YP2500X	Professional Counselor	001765	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10001263101	OTHER	MO	COMMUNITY HEALTH PLAN
2	22330031	OTHER	MO	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1316009574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE MARIE JOHNSON MS, LPC, NCC

Provider Business Mailing Address
First Line	:	5414 SAVANNAH RD
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64505-1146
Country	:	US
Telephone Number	:	816-364-4292
Fax Number	:	816-364-2648

Provider Business Practice Location Address
First Line	:	5414 SAVANNAH RD
Second Line	:
City	:	SAINT JOSEPH
State	:	MO
Zip	:	64505-1146
Country	:	US
Telephone Number	:	816-364-4292
Fax Number	:	816-364-2648

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/08/2007

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