MEDICARE: ALYSSA JOHNSON LISW-S

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

General Provider Information

NPI Number	:	1649907361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA JOHNSON LISW-S

Provider Business Mailing Address
First Line	:	1963 CHARMINGFARE ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-9399
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1963 CHARMINGFARE ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-9399
Country	:	US
Telephone Number	:	859-948-8952
Fax Number	:

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

Provider Enumeration Date	:	08/03/2022
Last Update Date	:	08/03/2022

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