Provider Demographics
NPI:1588797054
Name:WISDOM -JOHNSON, BIBIAN CAROL (SLP)
Entity Type:Individual
Prefix:
First Name:BIBIAN
Middle Name:CAROL
Last Name:WISDOM -JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2155
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-1730
Mailing Address - Country:US
Mailing Address - Phone:404-663-1867
Mailing Address - Fax:404-663-0774
Practice Address - Street 1:255 RACETRACK RD
Practice Address - Street 2:SUITE 12
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-6834
Practice Address - Country:US
Practice Address - Phone:404-663-1867
Practice Address - Fax:404-663-0774
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001995235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist