Provider Demographics
NPI:1265449789
Name:JOHNSON, LESLIE MARTIN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:MARTIN
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 1:604 BUCKSHOT CT
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-4496
Mailing Address - Country:US
Mailing Address - Phone:912-764-7833
Mailing Address - Fax:912-764-7833
Practice Address - Street 1:604 BUCKSHOT CT
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461-4496
Practice Address - Country:US
Practice Address - Phone:912-764-7833
Practice Address - Fax:912-764-7833
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP002048235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000885497AMedicaid