MEDICARE: ANTOINE 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	175T00000X	Peer Specialist	852373	PA

General Provider Information

NPI Number	:	1316545379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTOINE JOHNSON

Provider Business Mailing Address
First Line	:	846 N 63RD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19151-3443
Country	:	US
Telephone Number	:	121-538-8533
Fax Number	:

Provider Business Practice Location Address
First Line	:	846 N 63RD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19151-3443
Country	:	US
Telephone Number	:	121-538-8533
Fax Number	:

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

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	10/16/2020

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Directions to “ ANTOINE JOHNSON ” Practice Location

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