Provider Demographics
NPI:1033436936
Name:JOHNSON, NICOLE LYNN (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
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 235
Mailing Address - Street 2:
Mailing Address - City:QUECHEE
Mailing Address - State:VT
Mailing Address - Zip Code:05059-0235
Mailing Address - Country:US
Mailing Address - Phone:802-281-9102
Mailing Address - Fax:
Practice Address - Street 1:2066 QUECHEE MAIN STREET
Practice Address - Street 2:APARTMENT 4
Practice Address - City:QUECHEE
Practice Address - State:VT
Practice Address - Zip Code:05059
Practice Address - Country:US
Practice Address - Phone:802-281-9102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-01
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist