Provider Demographics
NPI:1295948297
Name:JOHNSON, MARJORIE LYNN (MA CCC)
Entity type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2782 AUTUMNWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3490
Mailing Address - Country:US
Mailing Address - Phone:952-545-5525
Mailing Address - Fax:
Practice Address - Street 1:6701 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4602
Practice Address - Country:US
Practice Address - Phone:952-993-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist