Provider Demographics
NPI:1619273463
Name:JOHNSON, STACY (M,S, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:M,S, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 LINDEN AVE
Mailing Address - Street 2:APT 6
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-1569
Mailing Address - Country:US
Mailing Address - Phone:909-573-4982
Mailing Address - Fax:
Practice Address - Street 1:424 N LAKE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1200
Practice Address - Country:US
Practice Address - Phone:626-793-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18545235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist