MEDICARE: MARK ANDREW JOHNSON

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	000473	NY

General Provider Information

NPI Number	:	1528274297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ANDREW JOHNSON

Provider Business Mailing Address
First Line	:	1563 GRAY RD
Second Line	:
City	:	UNION SPRINGS
State	:	NY
Zip	:	13160-4101
Country	:	US
Telephone Number	:	316-364-8118
Fax Number	:

Provider Business Practice Location Address
First Line	:	1563 GRAY RD
Second Line	:
City	:	UNION SPRINGS
State	:	NY
Zip	:	13160-4101
Country	:	US
Telephone Number	:	316-364-8118
Fax Number	:

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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