Provider Demographics
NPI:1679740658
Name:JOHNSON, GINA CHRISTINE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:CHRISTINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 SOUTH 70TH STREET
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:479-452-5013
Mailing Address - Fax:
Practice Address - Street 1:1813 S 70TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2750
Practice Address - Country:US
Practice Address - Phone:479-452-5013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist