Provider Demographics
NPI:1417172966
Name:JOHNSON, RUSSELL JR (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 GREGG ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3530
Mailing Address - Country:US
Mailing Address - Phone:803-779-2430
Mailing Address - Fax:803-779-3458
Practice Address - Street 1:1522 GREGG ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3530
Practice Address - Country:US
Practice Address - Phone:803-779-2430
Practice Address - Fax:803-779-3458
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC157237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist