Provider Demographics
NPI:1417200742
Name:JOHNSTON, LISA MAUREEN (CCC-SLP, LICENSED)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MAUREEN
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:CCC-SLP, LICENSED
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MAUREEN
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8419 116TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4707
Mailing Address - Country:US
Mailing Address - Phone:253-845-8537
Mailing Address - Fax:
Practice Address - Street 1:214 W MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5328
Practice Address - Country:US
Practice Address - Phone:253-841-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00001257235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist