Provider Demographics
NPI:1639314156
Name:JOHNSON, MOLLY KATHRYN (MA SLP)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:KATHRYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 ELMONT ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-7960
Mailing Address - Country:US
Mailing Address - Phone:321-726-8802
Mailing Address - Fax:
Practice Address - Street 1:7201 GREENBORO DR
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1698
Practice Address - Country:US
Practice Address - Phone:321-821-6736
Practice Address - Fax:321-724-5289
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist