Provider Demographics
NPI:1013493394
Name:JOHNSON, WRENELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:WRENELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3013
Mailing Address - Country:US
Mailing Address - Phone:718-593-4121
Mailing Address - Fax:
Practice Address - Street 1:3100 47TH AVE STE 2120
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3010
Practice Address - Country:US
Practice Address - Phone:718-268-2646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029378235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist