Provider Demographics
NPI:1417000282
Name:JOHNSON, THEODORE LEROY (AUD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:LEROY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WILSON WAY
Mailing Address - Street 2:
Mailing Address - City:DELANCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-5257
Mailing Address - Country:US
Mailing Address - Phone:609-895-1666
Mailing Address - Fax:
Practice Address - Street 1:177 FRANKLIN CORNER RD
Practice Address - Street 2:STE. 1B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2548
Practice Address - Country:US
Practice Address - Phone:609-895-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ336231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist