MEDICARE: YOLANDA LATRICE 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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1538610753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YOLANDA LATRICE JOHNSON

Provider Business Mailing Address
First Line	:	5048 CHURCH LAKE DR APT 1B
Second Line	:
City	:	SOUTHAVEN
State	:	MS
Zip	:	38671-8546
Country	:	US
Telephone Number	:	469-547-3881
Fax Number	:

Provider Business Practice Location Address
First Line	:	2165 SPICER CV STE 5
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-5623
Country	:	US
Telephone Number	:	469-547-3881
Fax Number	:

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

Provider Enumeration Date	:	10/24/2016
Last Update Date	:	10/24/2016

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