Provider Demographics
NPI:1609288414
Name:JOHNSON, PEGAN DANIELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PEGAN
Middle Name:DANIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:PEGAN
Other - Middle Name:DANIELLE
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 TROUP HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8397
Mailing Address - Country:US
Mailing Address - Phone:903-253-0095
Mailing Address - Fax:
Practice Address - Street 1:3200 TROUP HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8397
Practice Address - Country:US
Practice Address - Phone:903-253-0095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist