Provider Demographics
NPI:1346531688
Name:JOHNSON, MARILYN FAYE (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:FAYE
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 1:1356 GATE PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7843
Mailing Address - Country:US
Mailing Address - Phone:915-857-2505
Mailing Address - Fax:915-857-5355
Practice Address - Street 1:10450 BRIAN MOONEY AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-2809
Practice Address - Country:US
Practice Address - Phone:915-598-6616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15238235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist