MEDICARE: RIELLE JOHNSON PSYD

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	103TC0700X	Clinical Psychologist	6301016228	MI
2	103TC0700X	Clinical Psychologist	071010076	IL

General Provider Information

NPI Number	:	1831591197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RIELLE JOHNSON PSYD

Provider Business Mailing Address
First Line	:	1 E ERIE ST STE 525-2216
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	312-625-9051
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 E ERIE ST STE 525-2216
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	312-625-9051
Fax Number	:

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

Provider Enumeration Date	:	09/18/2014
Last Update Date	:	08/06/2022

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