Provider Demographics
NPI:1780832212
Name:JOHNSON, LINDA MARIE (MS)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BEVERLY WAY
Mailing Address - Street 2:AEGIS THERAPIES
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72919
Mailing Address - Country:US
Mailing Address - Phone:877-823-8375
Mailing Address - Fax:479-201-2703
Practice Address - Street 1:1703 60TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140
Practice Address - Country:US
Practice Address - Phone:262-658-4125
Practice Address - Fax:262-658-2196
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI602154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42725300Medicaid