Provider Demographics
NPI:1114609906
Name:JOHNSON, EMELINA IDA (AUD)
Entity Type:Individual
Prefix:
First Name:EMELINA
Middle Name:IDA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8038 MACINTOSH LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5336
Mailing Address - Country:US
Mailing Address - Phone:815-332-6800
Mailing Address - Fax:815-332-6810
Practice Address - Street 1:8038 MACINTOSH LN
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5336
Practice Address - Country:US
Practice Address - Phone:815-332-6800
Practice Address - Fax:815-332-6810
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001963231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist