Provider Demographics
NPI:1982014460
Name:JOHNSON, MIRANDA JEAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:MIRANDA
Other - Middle Name:JEAN
Other - Last Name:BENEVIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:9346 OAK AVENUE
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387
Mailing Address - Country:US
Mailing Address - Phone:952-223-2506
Mailing Address - Fax:952-443-2038
Practice Address - Street 1:15265 MINNETONKA BLVD.
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345
Practice Address - Country:US
Practice Address - Phone:952-223-2506
Practice Address - Fax:952-443-2038
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist