Provider Demographics
NPI:1740440874
Name:JOHNSON, BETH A (MA CCC SLP L)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC SLP L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W SPRINGFIELD AVE STE 702
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4845
Mailing Address - Country:US
Mailing Address - Phone:217-215-3016
Mailing Address - Fax:217-215-3016
Practice Address - Street 1:201 W SPRINGFIELD AVE STE 702
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4845
Practice Address - Country:US
Practice Address - Phone:217-215-3016
Practice Address - Fax:217-215-3016
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007061235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203OtherBLUE CROSS
IL7216OtherPERSONAL CARE
IL113326OtherHEALTHLINK
IL4117OtherHEALTH ALLIANCE
IL4117OtherHEALTH ALLIANCE