Provider Demographics
NPI:1114361391
Name:JOHNSON, PATRICIA MARIE (SLP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11650 LANTERN RD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2993
Mailing Address - Country:US
Mailing Address - Phone:317-576-8410
Mailing Address - Fax:888-654-4116
Practice Address - Street 1:11650 LANTERN RD
Practice Address - Street 2:SUITE 235
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2993
Practice Address - Country:US
Practice Address - Phone:317-576-8410
Practice Address - Fax:888-654-4116
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005399A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22005399AOtherINDIANA STATE LICENSE