MEDICARE: LISA ANN JOHNSON BA

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1437148962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANN JOHNSON BA

Provider Business Mailing Address
First Line	:	1955 US HIGHWAY 1 S
Second Line	:	SUITE C-2
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-3708
Country	:	US
Telephone Number	:	904-825-5048
Fax Number	:	904-825-6824

Provider Business Practice Location Address
First Line	:	1955 US HIGHWAY 1 S
Second Line	:	SUITE C-2
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-3708
Country	:	US
Telephone Number	:	904-825-5048
Fax Number	:	904-825-6824

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

Provider Enumeration Date	:	10/18/2005
Last Update Date	:	07/09/2007

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