MEDICARE: MARK 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1639470636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JOHNSON

Provider Business Mailing Address
First Line	:	3105 NEWCASTLE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75220-1637
Country	:	US
Telephone Number	:	214-432-6624
Fax Number	:

Provider Business Practice Location Address
First Line	:	4314 W LOVERS LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75209-2804
Country	:	US
Telephone Number	:	214-432-6624
Fax Number	:

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

Provider Enumeration Date	:	11/06/2010
Last Update Date	:	11/06/2010

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Directions to “ MARK JOHNSON ” Practice Location

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