MEDICARE: MITA M JOHNSON LPC, LMFT, LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	6450	CO
2	106H00000X	Marriage & Family Therapist	764	CO
3	101YP2500X	Professional Counselor	4215	CO

General Provider Information

NPI Number	:	1326195975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITA M JOHNSON LPC, LMFT, LAC

Provider Business Mailing Address
First Line	:	PO BOX 62359
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80962-2359
Country	:	US
Telephone Number	:	303-808-8466
Fax Number	:

Provider Business Practice Location Address
First Line	:	685 CITADEL DR E STE 510
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5372
Country	:	US
Telephone Number	:	303-808-8466
Fax Number	:

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

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	05/26/2024

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