MEDICARE: T KELLY JOHNSON 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		SD

General Provider Information

NPI Number	:	1568537058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	T KELLY JOHNSON LAC

Provider Business Mailing Address
First Line	:	726 S WASHINGTON AVE
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-3519
Country	:	US
Telephone Number	:	605-270-0347
Fax Number	:

Provider Business Practice Location Address
First Line	:	726 S WASHINGTON AVE
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-3519
Country	:	US
Telephone Number	:	605-270-0347
Fax Number	:

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	04/14/2015

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