Provider Demographics
NPI:1619151735
Name:MCKINNEY JOHNSON, MADORA (SLP)
Entity Type:Individual
Prefix:
First Name:MADORA
Middle Name:
Last Name:MCKINNEY 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 1:6100 OLD BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2543
Mailing Address - Country:US
Mailing Address - Phone:601-638-4076
Mailing Address - Fax:601-883-2232
Practice Address - Street 1:1901 MISSION 66
Practice Address - Street 2:SUITE A
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-638-4076
Practice Address - Fax:601-883-2232
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3182235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000050976OtherBCBS OF MISSISSIPPI
MS000050976OtherBCBS OF MISSISSIPPI