Provider Demographics
NPI:1790137834
Name:JOHNSON, NICHOLE (MA, CCC/SLP-L)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, CCC/SLP-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30437 UNIVERSITY RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:SD
Mailing Address - Zip Code:57014-6536
Mailing Address - Country:US
Mailing Address - Phone:605-563-2291
Mailing Address - Fax:
Practice Address - Street 1:610 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:SD
Practice Address - Zip Code:57014-2040
Practice Address - Country:US
Practice Address - Phone:605-563-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD015-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist