Provider Demographics
NPI:1750835237
Name:JOHNSON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2511
Mailing Address - Country:US
Mailing Address - Phone:814-375-0455
Mailing Address - Fax:814-375-2721
Practice Address - Street 1:871 BEAVER DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2511
Practice Address - Country:US
Practice Address - Phone:814-375-0455
Practice Address - Fax:814-375-2721
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAF03656237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist