MEDICARE: LYNNETTE JOHNSON LLC

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	251S00000X	Community/Behavioral Health Agency	01060	NV
2	106H00000X	Marriage & Family Therapist	01060	NV

General Provider Information

NPI Number	:	1750694253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYNNETTE JOHNSON LLC

Provider Business Mailing Address
First Line	:	1641 E FLAMINGO RD
Second Line	:	SUITE 7
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5257
Country	:	US
Telephone Number	:	702-434-1564
Fax Number	:	702-434-6704

Provider Business Practice Location Address
First Line	:	1641 E FLAMINGO RD
Second Line	:	SUITE 7
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5257
Country	:	US
Telephone Number	:	702-434-1564
Fax Number	:	702-434-6704

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LYNNETTE ELAINE JOHNSON
Credential	:	MA, MFT, LADC
Telephone Number	:	702-434-1564

Provider Enumeration Date	:	07/26/2010
Last Update Date	:	10/19/2012

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