MEDICARE: MISS STACY LAUREN 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	104100000X	Social Worker	S.2411665	OH
2	171M00000X	Case Manager/Care Coordinator
3	172V00000X	Community Health Worker	CHW.002542	OH
4	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1619718657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS STACY LAUREN JOHNSON

Provider Business Mailing Address
First Line	:	3079 BECKET RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-2709
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3079 BECKET RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-2709
Country	:	US
Telephone Number	:	216-296-0035
Fax Number	:

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

Provider Enumeration Date	:	06/04/2024
Last Update Date	:	11/20/2024

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