Provider Demographics
NPI:1861866329
Name:JOHNSON, MATTHEW (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
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 1:170 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1347
Mailing Address - Country:US
Mailing Address - Phone:740-446-7112
Mailing Address - Fax:740-441-9088
Practice Address - Street 1:170 PINECREST DR
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1347
Practice Address - Country:US
Practice Address - Phone:740-446-7112
Practice Address - Fax:740-441-9088
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.11359235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist