Provider Demographics
NPI:1326224031
Name:JOHNSON, AMY WACLAWSKI (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:WACLAWSKI
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 GARDNERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3795
Mailing Address - Country:US
Mailing Address - Phone:706-855-5631
Mailing Address - Fax:
Practice Address - Street 1:135 GARDNERS MILL RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3795
Practice Address - Country:US
Practice Address - Phone:706-855-5631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003751231H00000X
SC3409231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist