Provider Demographics
NPI:1457385916
Name:JOHNSON, MARY ANNA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 BURROWS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-9775
Mailing Address - Country:US
Mailing Address - Phone:916-698-5752
Mailing Address - Fax:866-848-1366
Practice Address - Street 1:3475 BURROWS AVE
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-9775
Practice Address - Country:US
Practice Address - Phone:916-698-5752
Practice Address - Fax:866-848-1366
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7421235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist