Provider Demographics
NPI:1134621675
Name:JOHNSON, BREANNA LYNN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 JAIN LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78721-3022
Mailing Address - Country:US
Mailing Address - Phone:512-940-7865
Mailing Address - Fax:
Practice Address - Street 1:3520 EXECUTIVE CENTER DR STE 128
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1636
Practice Address - Country:US
Practice Address - Phone:612-343-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112860235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist