Provider Demographics
NPI:1134322324
Name:JOHNSON, TRACY L (EDD CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:EDD CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 FEATHER RUN TRL
Mailing Address - Street 2:APT. E20
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4966
Mailing Address - Country:US
Mailing Address - Phone:803-926-3699
Mailing Address - Fax:
Practice Address - Street 1:2700 FEATHER RUN TRL
Practice Address - Street 2:APT. E20
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4966
Practice Address - Country:US
Practice Address - Phone:803-926-3699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3595235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0559Medicaid