Provider Demographics
NPI:1053482216
Name:JOHNSON, BEVERLY (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 CARPENTER FLETCHER RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-1940
Mailing Address - Country:US
Mailing Address - Phone:919-544-9765
Mailing Address - Fax:919-544-5654
Practice Address - Street 1:710 CARPENTER FLETCHER RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1940
Practice Address - Country:US
Practice Address - Phone:919-544-9765
Practice Address - Fax:919-544-5654
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411715Medicaid