Provider Demographics
NPI:1669021499
Name:JOHNSON, CHRISTINA RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:RODRIGUEZ
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 NORTHEAST EXPY NE STE 120
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2475
Mailing Address - Country:US
Mailing Address - Phone:404-228-8558
Mailing Address - Fax:404-228-8659
Practice Address - Street 1:1777 NORTHEAST EXPY NE STE 120
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2475
Practice Address - Country:US
Practice Address - Phone:404-228-8558
Practice Address - Fax:404-228-8659
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009728235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14087060OtherASHA LICENSE