Provider Demographics
NPI:1871179747
Name:JOHNSON, MATTHEW EMERSON (HA61109811)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EMERSON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:HA61109811
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22055 129TH PL SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3937
Mailing Address - Country:US
Mailing Address - Phone:206-427-2604
Mailing Address - Fax:
Practice Address - Street 1:10413 BEARDSLEE BLVD
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3463
Practice Address - Country:US
Practice Address - Phone:425-485-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA61109811237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist