Provider Demographics
NPI:1235193699
Name:JOHNSON, MARY CAROLINE (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROLINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3356 GRASMERE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-4020
Mailing Address - Country:US
Mailing Address - Phone:859-223-4805
Mailing Address - Fax:
Practice Address - Street 1:1101 VETERANS DR
Practice Address - Street 2:126-CDD
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-2235
Practice Address - Country:US
Practice Address - Phone:859-281-4972
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0941235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist