Provider Demographics
NPI:1952823452
Name:HUMPHREYS JOHNSON, SARAH KATHLEEN
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:KATHLEEN
Last Name:HUMPHREYS JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:KATHLEEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4123 SOUTHPARK DR APT 131
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1847
Mailing Address - Country:US
Mailing Address - Phone:903-522-1385
Mailing Address - Fax:
Practice Address - Street 1:100 E FERGUSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5759
Practice Address - Country:US
Practice Address - Phone:903-509-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113627235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist