Provider Demographics
NPI:1790455947
Name:JOHNSON, SAMUEL TIMOTHY (AUD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:TIMOTHY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 OLYMPIC BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5094
Mailing Address - Country:US
Mailing Address - Phone:707-494-4328
Mailing Address - Fax:
Practice Address - Street 1:1900 OLYMPIC BLVD STE 202
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5094
Practice Address - Country:US
Practice Address - Phone:707-494-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-19
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU3617237600000X
WALD61186783237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter