Provider Demographics
NPI:1437626736
Name:JOHNSON, CHRISTY GAIL (SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:GAIL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:GAIL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1337 N HIGHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2213
Mailing Address - Country:US
Mailing Address - Phone:503-750-6752
Mailing Address - Fax:
Practice Address - Street 1:840 SW 4TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2638
Practice Address - Country:US
Practice Address - Phone:541-881-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist