Provider Demographics
NPI:1669918421
Name:JOHNSON, MARY LOU B (MS)
Entity type:Individual
Prefix:MS
First Name:MARY LOU
Middle Name:B
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:BRECHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:9139 RIDGELINE BLVD
Mailing Address - Street 2:100
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2333
Mailing Address - Country:US
Mailing Address - Phone:720-478-2370
Mailing Address - Fax:720-478-7069
Practice Address - Street 1:9139 RIDGELINE BLVD
Practice Address - Street 2:100
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2333
Practice Address - Country:US
Practice Address - Phone:720-478-2370
Practice Address - Fax:720-478-7069
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000509235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist