Provider Demographics
NPI:1831297571
Name:JOHNSON, ELLEN BETH (MS/CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:BETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS/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:PO BOX 1286
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-1286
Mailing Address - Country:US
Mailing Address - Phone:928-537-1705
Mailing Address - Fax:
Practice Address - Street 1:120 N. 8TH AVE
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901
Practice Address - Country:US
Practice Address - Phone:928-537-1705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1079235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist