MEDICARE: DR. NICOLE GABBRIELLE JOHNSON PH.D, LPC, CAADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	5651	PA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	7378	PA
3	101YP2500X	Professional Counselor	PC005270	PA

General Provider Information

NPI Number	:	1962795922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE GABBRIELLE JOHNSON PH.D, LPC, CAADC

Provider Business Mailing Address
First Line	:	7550 RUGBY ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-2608
Country	:	US
Telephone Number	:	215-313-1743
Fax Number	:

Provider Business Practice Location Address
First Line	:	7550 RUGBY ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-2608
Country	:	US
Telephone Number	:	215-313-1743
Fax Number	:

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

Provider Enumeration Date	:	05/24/2011
Last Update Date	:	03/14/2017

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