Provider Demographics
NPI:1184851263
Name:JOHNSON, MARY BETH (MS,CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
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 1:31411 EVERGREEN PARK LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77385-7911
Mailing Address - Country:US
Mailing Address - Phone:832-452-2068
Mailing Address - Fax:
Practice Address - Street 1:31411 EVERGREEN PARK LN
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77385-7911
Practice Address - Country:US
Practice Address - Phone:832-452-2068
Practice Address - Fax:281-419-7076
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102280235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist