Provider Demographics
NPI:1467656199
Name:JOHNSON, STACEY ANN (MHS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MHS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 N CALIFORNIA AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2637
Mailing Address - Country:US
Mailing Address - Phone:312-545-0383
Mailing Address - Fax:
Practice Address - Street 1:2922 N SEELEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-8211
Practice Address - Country:US
Practice Address - Phone:312-545-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011918235Z00000X
MO2007016503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist