MEDICARE: KYLIE R. JOHNSON CRM

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	101YM0800X	Mental Health Counselor	257467	OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	T221364	OR
3	175T00000X	Peer Specialist	21-CRM-428	OR

General Provider Information

NPI Number	:	1952989956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLIE R. JOHNSON CRM

Provider Business Mailing Address
First Line	:	389 SW SCALEHOUSE CT STE 130
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3241
Country	:	US
Telephone Number	:	541-306-4446
Fax Number	:	541-512-7090

Provider Business Practice Location Address
First Line	:	389 SW SCALEHOUSE CT STE 130
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-3241
Country	:	US
Telephone Number	:	541-306-4446
Fax Number	:	541-512-7090

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

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	11/10/2025

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