Provider Demographics
NPI:1639419948
Name:JOHNSON, MARK F (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2957 WINGLEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 TROUBLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-5642
Practice Address - Country:US
Practice Address - Phone:727-375-2999
Practice Address - Fax:727-569-1667
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8062235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist