Provider Demographics
NPI:1093192759
Name:JOHNSON, DIANE MASON (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MASON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 TRAVIS ST APT 11D
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-4767
Mailing Address - Country:US
Mailing Address - Phone:210-724-8812
Mailing Address - Fax:
Practice Address - Street 1:612 TRAVIS ST APT 11D
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-4767
Practice Address - Country:US
Practice Address - Phone:210-724-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist