MEDICARE: AMANDA MARIE JOHNSON LCDCII

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	1041C0700X	Clinical Social Worker	I.2506279	OH
2	103TA0400X	Addiction (Substance Use Disorder) Psychologist	LCDCII.161326	OH

General Provider Information

NPI Number	:	1891284717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MARIE JOHNSON LCDCII

Provider Business Mailing Address
First Line	:	1899 LOWER BELLBROOK RD
Second Line	:
City	:	XENIA
State	:	OH
Zip	:	45385-9310
Country	:	US
Telephone Number	:	937-613-9537
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 E 3RD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-1850
Country	:	US
Telephone Number	:	937-387-6395
Fax Number	:

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

Provider Enumeration Date	:	05/07/2018
Last Update Date	:	03/26/2025

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