Provider Demographics
NPI:1689928822
Name:JOHNSON, SHANON HODGES (SLP)
Entity Type:Individual
Prefix:MRS
First Name:SHANON
Middle Name:HODGES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BILTMORE TURN
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-7038
Mailing Address - Country:US
Mailing Address - Phone:601-467-0410
Mailing Address - Fax:
Practice Address - Street 1:12 BILTMORE TURN
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-7038
Practice Address - Country:US
Practice Address - Phone:601-467-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2480235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist