Provider Demographics
NPI:1477862043
Name:JOHNSON, KELLY ANITA (MCD-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANITA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MCD-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 ELLIS RD
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-8906
Mailing Address - Country:US
Mailing Address - Phone:870-647-3524
Mailing Address - Fax:870-647-2301
Practice Address - Street 1:74 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:AR
Practice Address - Zip Code:72444-9225
Practice Address - Country:US
Practice Address - Phone:870-647-3524
Practice Address - Fax:870-647-2301
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist