MEDICARE: MS. RAE LYNN 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
1	1041C0700X	Clinical Social Worker	SW4297	FL

General Provider Information

NPI Number	:	1639357932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RAE LYNN JOHNSON LCSW

Provider Business Mailing Address
First Line	:	1920 S OCEAN DR
Second Line	:	UNIT 1202
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33316-3764
Country	:	US
Telephone Number	:	954-593-3564
Fax Number	:	954-587-0040

Provider Business Practice Location Address
First Line	:	1920 S OCEAN DR
Second Line	:	UNIT 1202
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33316-3764
Country	:	US
Telephone Number	:	954-593-3564
Fax Number	:	954-587-0040

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

Provider Enumeration Date	:	02/08/2008
Last Update Date	:	02/08/2008

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