Provider Demographics
NPI:1407578115
Name:GRAY, JOHANNA LIDSKY (CFY-SLP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LIDSKY
Last Name:GRAY
Suffix:
Gender:F
Credentials:CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HAYDEN LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-1302
Mailing Address - Country:US
Mailing Address - Phone:508-269-5964
Mailing Address - Fax:
Practice Address - Street 1:8229 BOONE BLVD STE 660
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2657
Practice Address - Country:US
Practice Address - Phone:703-821-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSLPCF2000054235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist