Provider Demographics
NPI:1003420910
Name:JOHNSON, SHOMA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHOMA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 169TH ST APT C1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1841
Mailing Address - Country:US
Mailing Address - Phone:678-622-1933
Mailing Address - Fax:
Practice Address - Street 1:3506 169TH ST APT C1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1841
Practice Address - Country:US
Practice Address - Phone:678-622-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14302844235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist