Provider Demographics
NPI:1336331099
Name:JOHNSON-BROWN, KETURAH MICHELLE (CCC,SLP)
Entity Type:Individual
Prefix:MS
First Name:KETURAH
Middle Name:MICHELLE
Last Name:JOHNSON-BROWN
Suffix:
Gender:F
Credentials:CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5406 EMERALD REEF CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-1381
Mailing Address - Country:US
Mailing Address - Phone:904-629-5838
Mailing Address - Fax:904-629-5838
Practice Address - Street 1:5406 EMERALD REEF CT
Practice Address - Street 2:SUITE 102
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-1381
Practice Address - Country:US
Practice Address - Phone:904-629-5838
Practice Address - Fax:904-629-5838
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5067235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886949900Medicaid