Provider Demographics
NPI:1265675748
Name:JOHNSON, MARY A (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-1253
Mailing Address - Country:US
Mailing Address - Phone:615-896-6400
Mailing Address - Fax:
Practice Address - Street 1:1650 SE HOLIDAY CREST CIR
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-8661
Practice Address - Country:US
Practice Address - Phone:615-896-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001908235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist