Provider Demographics
NPI:1558875799
Name:JOHNSON, LISA M (MA CCC/SLP/L)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC/SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7875 TODD RD
Mailing Address - Street 2:
Mailing Address - City:SHABBONA
Mailing Address - State:IL
Mailing Address - Zip Code:60550-4162
Mailing Address - Country:US
Mailing Address - Phone:815-824-8152
Mailing Address - Fax:
Practice Address - Street 1:3520 KISHWAUKEE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2005
Practice Address - Country:US
Practice Address - Phone:815-229-2870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.004910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.004910Medicaid