MEDICARE: FANNY ALAEZ JOHNSON MA

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	101YP2500X	Professional Counselor	6401011740	MI

General Provider Information

NPI Number	:	1932670924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANNY ALAEZ JOHNSON MA

Provider Business Mailing Address
First Line	:	PO BOX 294
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-0294
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 NILES RD STE 7
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-3268
Country	:	US
Telephone Number	:	269-281-0407
Fax Number	:	269-281-7620

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

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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