Provider Demographics
NPI:1891073748
Name:JOHANSSEN, TAMMY (MED, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:JOHANSSEN
Suffix:
Gender:F
Credentials:MED, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-3946
Mailing Address - Country:US
Mailing Address - Phone:910-299-0700
Mailing Address - Fax:910-299-0800
Practice Address - Street 1:600 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-3946
Practice Address - Country:US
Practice Address - Phone:910-299-0700
Practice Address - Fax:910-299-0800
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7413581Medicaid