Provider Demographics
NPI:1790317329
Name:JOHNSON, CARLY JEAN (SLP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5202 OLYMPIC DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1727
Mailing Address - Country:US
Mailing Address - Phone:253-851-0007
Mailing Address - Fax:
Practice Address - Street 1:5202 OLYMPIC DR STE 100
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1727
Practice Address - Country:US
Practice Address - Phone:253-851-0007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist