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NPI Code Detail

MEDICARE: DIANE C JOHNSON LCSW

MEDICARE: DIANE C JOHNSON LCSW
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
11041C0700XClinical Social Worker149010033IL

General Provider Information

NPI Number : 1518300268
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIANE C JOHNSON LCSW
Provider Business Mailing Address
First Line : 20178 N HAILS LN
Second Line :
City : TEXICO
State : IL
Zip : 62889-2921
Country : US
Telephone Number : 618-899-1435
Fax Number :
Provider Business Practice Location Address
First Line : 1 GOOD SAMARITAN WAY
Second Line :
City : MOUNT VERNON
State : IL
Zip : 62864-2402
Country : US
Telephone Number : 618-899-1435
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/12/2013
Last Update Date : 04/12/2013

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