Provider Demographics
NPI:1134885551
Name:JOHNSON, MADISON REIDE (AUD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:REIDE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 W I 35 FRONTAGE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8555
Mailing Address - Country:US
Mailing Address - Phone:405-757-3710
Mailing Address - Fax:405-757-3711
Practice Address - Street 1:2017 W I 35 FRONTAGE RD STE 140
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8555
Practice Address - Country:US
Practice Address - Phone:405-757-3710
Practice Address - Fax:405-757-3711
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5590231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist