Provider Demographics
NPI:1093065393
Name:JOHNSON, VIRGINIA CLIPSON (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:CLIPSON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 COPPERFIELD PARKWAY #827
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845
Mailing Address - Country:US
Mailing Address - Phone:210-601-6787
Mailing Address - Fax:
Practice Address - Street 1:1401 W. MARTIN LUTHER KING
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803
Practice Address - Country:US
Practice Address - Phone:979-209-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11157235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist