Provider Demographics
NPI:1770009912
Name:JOHNSON, DANIEL MALCOLM
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:MALCOLM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 NE 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 NW FRIBERG STRUNK ST
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7697
Practice Address - Country:US
Practice Address - Phone:360-604-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist