MEDICARE: GRANT JOHNSON

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

General Provider Information

NPI Number	:	1952796930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT JOHNSON

Provider Business Mailing Address
First Line	:	215 NE 28TH ST
Second Line	:	#2411
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-2840
Country	:	US
Telephone Number	:	405-596-2369
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 NE 28TH ST
Second Line	:	#2411
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-2840
Country	:	US
Telephone Number	:	405-596-2369
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	GRANT DEAN JOHNSON
Credential	:	M.A.
Telephone Number	:	405-596-2369

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/06/2015

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Directions to “GRANT JOHNSON ” Practice Location

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