Provider Demographics
NPI:1174863849
Name:JOHNSON, DIANE MARIE (MS,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
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 1:192 HARVINGTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617
Mailing Address - Country:US
Mailing Address - Phone:585-317-2424
Mailing Address - Fax:
Practice Address - Street 1:1000 ELMWOOD AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3042
Practice Address - Country:US
Practice Address - Phone:585-317-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012738-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist