Provider Demographics
NPI:1790397099
Name:JOHNSON, MOLLY G (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:G
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 S 147TH ST STE 109-111
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5565
Mailing Address - Country:US
Mailing Address - Phone:402-942-1329
Mailing Address - Fax:402-606-4664
Practice Address - Street 1:3925 S 147TH ST STE 109-111
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5565
Practice Address - Country:US
Practice Address - Phone:402-942-1329
Practice Address - Fax:402-606-4664
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2529235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist