Provider Demographics
NPI:1689076390
Name:JOHNSON, STEPHANIE MARIE (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5473 MOCERI LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-4369
Mailing Address - Country:US
Mailing Address - Phone:810-423-1076
Mailing Address - Fax:
Practice Address - Street 1:5103 W PIERSON RD
Practice Address - Street 2:SUITE #3
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-1395
Practice Address - Country:US
Practice Address - Phone:810-423-1076
Practice Address - Fax:810-391-2968
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist