Provider Demographics
NPI:1336375716
Name:JOHNSON, DIANA (MS)
Entity Type:Individual
Prefix:MISS
First Name:DIANA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-4002
Mailing Address - Country:US
Mailing Address - Phone:917-923-6504
Mailing Address - Fax:718-855-9298
Practice Address - Street 1:931 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-4002
Practice Address - Country:US
Practice Address - Phone:917-923-6504
Practice Address - Fax:718-855-9540
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07577-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist