Provider Demographics
NPI:1790848802
Name:JOHNSON, ELYSE (SLP)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
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 1:4120 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6104
Mailing Address - Country:US
Mailing Address - Phone:307-333-2873
Mailing Address - Fax:307-333-4034
Practice Address - Street 1:455 THELMA DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2324
Practice Address - Country:US
Practice Address - Phone:307-472-3327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2853235Z00000X
WYSP-732235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist