Provider Demographics
NPI:1669849170
Name:JOHNSON, SANDRA GAYLE
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:GAYLE
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 1:1306 JILL LANE
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024
Mailing Address - Country:US
Mailing Address - Phone:816-630-5751
Mailing Address - Fax:
Practice Address - Street 1:749 DRISKILL DRIVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MO
Practice Address - Zip Code:64085
Practice Address - Country:US
Practice Address - Phone:816-776-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO463521203Medicaid