Provider Demographics
NPI:1740564442
Name:JOHNSON, ELIZABETH MARIE
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIZZIE
Other - Middle Name:MARIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5308 CAROLINA CROSSINGS WAY
Mailing Address - Street 2:102
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-2380
Mailing Address - Country:US
Mailing Address - Phone:502-314-7093
Mailing Address - Fax:
Practice Address - Street 1:5308 CAROLINA CROSSINGS WAY
Practice Address - Street 2:102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-2380
Practice Address - Country:US
Practice Address - Phone:502-314-7093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201123576222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist