Provider Demographics
NPI:1639218514
Name:JOHNSON, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:MONTOYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:3009 HUBBARD LN
Mailing Address - Street 2:SUITE G
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4800
Mailing Address - Country:US
Mailing Address - Phone:707-443-3584
Mailing Address - Fax:
Practice Address - Street 1:3009 HUBBARD LN
Practice Address - Street 2:SUITE G
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4800
Practice Address - Country:US
Practice Address - Phone:707-443-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP8035235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA63EMedicaid