MEDICARE: LLYR TOBIAS JOHNASEN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1679308258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LLYR TOBIAS JOHNASEN

Provider Business Mailing Address
First Line	:	735 BAILEY AVE
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-1254
Country	:	US
Telephone Number	:	310-776-5597
Fax Number	:

Provider Business Practice Location Address
First Line	:	2426 7TH AVE STE 2
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95818-3912
Country	:	US
Telephone Number	:	310-776-5597
Fax Number	:

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

Provider Enumeration Date	:	09/04/2024
Last Update Date	:	09/04/2024

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