Provider Demographics
NPI:1417362872
Name:JOHNSON, ALISSA
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 DE ANZA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 TWIN DOLPHIN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-1133
Practice Address - Country:US
Practice Address - Phone:650-318-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8823235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist