Provider Demographics
NPI:1033255328
Name:JOHNSON, DOUGLAS ARTHUR (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ARTHUR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials: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:PO BOX 4492
Mailing Address - Street 2:804 VILLAGE DRIVE
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-4492
Mailing Address - Country:US
Mailing Address - Phone:928-645-1414
Mailing Address - Fax:
Practice Address - Street 1:500 NORTH NAVAJO
Practice Address - Street 2:BOX 1927
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-608-4300
Practice Address - Fax:928-645-9285
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP4920OtherLICENSE-AZ DEPT OF HEALT