Provider Demographics
NPI:1871860817
Name:JOHNSON, KELLIE SIMPSON (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:SIMPSON
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 1:5106 W RUNNING BROOK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-1522
Mailing Address - Country:US
Mailing Address - Phone:443-319-5251
Mailing Address - Fax:443-319-5251
Practice Address - Street 1:5106 W RUNNING BROOK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-1522
Practice Address - Country:US
Practice Address - Phone:443-319-5251
Practice Address - Fax:443-319-5251
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04564235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist