Provider Demographics
NPI:1093228504
Name:JOHNSON, KELSEY GRACE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:GRACE
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 1:131 POINDEXTER DR UNIT 1115
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-0056
Mailing Address - Country:US
Mailing Address - Phone:815-861-1862
Mailing Address - Fax:
Practice Address - Street 1:1010 E GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4521
Practice Address - Country:US
Practice Address - Phone:704-868-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist