Provider Demographics
NPI:1245443787
Name:JOHNSON, JANICE L (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:L
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 1:515 E GRANT RD STE 141
Mailing Address - Street 2:PMB 269
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-5700
Mailing Address - Country:US
Mailing Address - Phone:520-624-8298
Mailing Address - Fax:
Practice Address - Street 1:515 E GRANT RD STE 141
Practice Address - Street 2:PMB 269
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-5700
Practice Address - Country:US
Practice Address - Phone:520-624-8298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ613374Medicare ID - Type Unspecified