Provider Demographics
NPI:1770633976
Name:JOHNSON, SUZANNE L (MS-CCC SLP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS-CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14637 STONEHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-3483
Mailing Address - Country:US
Mailing Address - Phone:708-466-4111
Mailing Address - Fax:708-645-5687
Practice Address - Street 1:14637 STONEHAVEN LN
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-3483
Practice Address - Country:US
Practice Address - Phone:708-466-4111
Practice Address - Fax:708-645-5687
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09928235OtherBCBS PROVIDER NUMBER