Provider Demographics
NPI:1851448153
Name:JOHNSON, HEIDI S (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:S
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 1:5955 THANE RD
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7731
Mailing Address - Country:US
Mailing Address - Phone:907-723-3130
Mailing Address - Fax:907-364-1543
Practice Address - Street 1:9109 MENDENHALL MALL RD
Practice Address - Street 2:SUITE 2
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7113
Practice Address - Country:US
Practice Address - Phone:907-723-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK82235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP3452Medicaid