MEDICARE: MR. KIRK JOHNSON LPC, 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	207	CO
2	101YM0800X	Mental Health Counselor	6516	CO

General Provider Information

NPI Number	:	1437574209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KIRK JOHNSON LPC, LAC

Provider Business Mailing Address
First Line	:	PO BOX 216
Second Line	:
City	:	BLACK HAWK
State	:	CO
Zip	:	80422-0216
Country	:	US
Telephone Number	:	303-867-4613
Fax Number	:	303-582-3454

Provider Business Practice Location Address
First Line	:	770 W HAMPDEN AVE STE 205
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80110-2130
Country	:	US
Telephone Number	:	303-481-0388
Fax Number	:

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

Provider Enumeration Date	:	03/03/2014
Last Update Date	:	09/24/2019

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