Provider Demographics
NPI:1770758286
Name:JOHNSON, TARA RENEE (MS, CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:RENEE
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 1:1995 E CORNELIUS HARNETT BLVD
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-8276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 E CORNELIUS HARNETT BLVD
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-8276
Practice Address - Country:US
Practice Address - Phone:919-800-7445
Practice Address - Fax:919-814-0890
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7970235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist