Provider Demographics
NPI:1396222626
Name:JOHNAON, REBECCA L (SPEECH AND LANGUAGE)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:L
Last Name:JOHNAON
Suffix:
Gender:F
Credentials:SPEECH AND LANGUAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 E.HAMILTON
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64501-3904
Mailing Address - Country:US
Mailing Address - Phone:660-665-4631
Mailing Address - Fax:660-665-3281
Practice Address - Street 1:1300 S. COTTAGE GROVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-6350
Practice Address - Country:US
Practice Address - Phone:660-665-4631
Practice Address - Fax:660-665-4631
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100354235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100534OtherDEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION