MEDICARE: LISA L JOHNSON TAYLOR MA, LP

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	103T00000X	Psychologist	LP3787	MN

General Provider Information

NPI Number	:	1508945452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA L JOHNSON TAYLOR MA, LP

Provider Business Mailing Address
First Line	:	1751 SOUTHCROSS DR W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-7012
Country	:	US
Telephone Number	:	952-892-7690
Fax Number	:	952-898-4930

Provider Business Practice Location Address
First Line	:	1751 SOUTHCROSS DR W
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-7012
Country	:	US
Telephone Number	:	952-892-7690
Fax Number	:	952-898-4930

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	07/28/2014

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