Provider Demographics
NPI:1952499212
Name:JOHNSON, CARISSA (MS, CCC)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 GRANITE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-1845
Mailing Address - Country:US
Mailing Address - Phone:813-220-2730
Mailing Address - Fax:
Practice Address - Street 1:5207 GRANITE RIDGE DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-1845
Practice Address - Country:US
Practice Address - Phone:813-220-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA7318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812018800Medicaid
FLS2755OtherBC/BS OF FLORIDA #
FL889202400Medicaid
FL812018800Medicaid