Provider Demographics
NPI:1902380157
Name:JOHNSON, CAROLINE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4717 TWIN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3536
Mailing Address - Country:US
Mailing Address - Phone:512-297-5955
Mailing Address - Fax:
Practice Address - Street 1:419 W PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-6535
Practice Address - Country:US
Practice Address - Phone:512-297-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-23
Last Update Date:2018-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115118235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty