MEDICARE: LIEUTENANT JOHNSON SUPERVILLE PH.D

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	847157	NV

General Provider Information

NPI Number	:	1790458156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIEUTENANT JOHNSON SUPERVILLE PH.D

Provider Business Mailing Address
First Line	:	6301 MOUNTAIN VISTA ST STE 104
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-2365
Country	:	US
Telephone Number	:	512-201-6766
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 MOUNTAIN VISTA ST STE 104
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-2365
Country	:	US
Telephone Number	:	512-201-6766
Fax Number	:

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

Provider Enumeration Date	:	07/30/2021
Last Update Date	:	12/05/2025

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