Provider Demographics
NPI:1265462600
Name:JOHNSON, PAULA TENPAS (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:TENPAS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WESTERN AVE
Mailing Address - Street 2:PO BOX 2170
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-2170
Mailing Address - Country:US
Mailing Address - Phone:920-320-8667
Mailing Address - Fax:920-320-8616
Practice Address - Street 1:600 YORK ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-6845
Practice Address - Country:US
Practice Address - Phone:920-320-6850
Practice Address - Fax:920-682-1981
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI561-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI709070OtherT19 MANAGED HEALTH SERVIC
WI42680200Medicaid