Provider Demographics
NPI:1104395987
Name:JOHNSON, AUDREA JENEZ (SLPA #3261)
Entity Type:Individual
Prefix:MISS
First Name:AUDREA
Middle Name:JENEZ
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLPA #3261
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 AUTO CENTER DR
Mailing Address - Street 2:#D
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:73551
Mailing Address - Country:US
Mailing Address - Phone:661-945-7878
Mailing Address - Fax:661-945-7553
Practice Address - Street 1:861 AUTO CENTER DR
Practice Address - Street 2:#D
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:73551
Practice Address - Country:US
Practice Address - Phone:661-945-7878
Practice Address - Fax:661-945-7553
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32612355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant