Provider Demographics
NPI:1093843583
Name:JOHNSON, TYLER (MS, CCC SLP)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
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 1:2238 N LAWNDALE AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2343
Mailing Address - Country:US
Mailing Address - Phone:773-327-0629
Mailing Address - Fax:773-327-0547
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:BOX 142
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-327-0629
Practice Address - Fax:773-327-0547
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist