Provider Demographics
NPI:1407026800
Name:JOHNSON BRUNSON, SHARON ALISSA (MA CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:ALISSA
Last Name:JOHNSON BRUNSON
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-3907
Mailing Address - Country:US
Mailing Address - Phone:803-707-6962
Mailing Address - Fax:803-937-5642
Practice Address - Street 1:397 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-3907
Practice Address - Country:US
Practice Address - Phone:803-707-6962
Practice Address - Fax:803-937-5642
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2255235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA093Medicaid