Provider Demographics
NPI:1689675092
Name:JOHNSON, THUMPER VL (MA CCC ASLP)
Entity Type:Individual
Prefix:
First Name:THUMPER
Middle Name:VL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC ASLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 E EMPORIA
Mailing Address - Street 2:STE 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3788
Mailing Address - Country:US
Mailing Address - Phone:316-263-0296
Mailing Address - Fax:316-684-3326
Practice Address - Street 1:310 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-2129
Practice Address - Country:US
Practice Address - Phone:316-684-2838
Practice Address - Fax:316-684-3326
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS37235Z00000X, 237600000X
KS837237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
640004569OtherMC RAILROAD
P25088Medicare UPIN
115349Medicare ID - Type Unspecified