Provider Demographics
NPI:1023018843
Name:JOHNSON, KATHLEEN S (CCC-A)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ALLEN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4564
Mailing Address - Country:US
Mailing Address - Phone:802-775-3314
Mailing Address - Fax:802-775-9617
Practice Address - Street 1:69 ALLEN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4564
Practice Address - Country:US
Practice Address - Phone:802-775-3314
Practice Address - Fax:802-775-9617
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT063-0000170231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT101-0801Medicaid
VT040664Medicare ID - Type Unspecified