Provider Demographics
NPI:1770774382
Name:JOHNSON, LIELA BANKS
Entity type:Individual
Prefix:
First Name:LIELA
Middle Name:BANKS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIELA
Other - Middle Name:B
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA,CCC-SLP
Mailing Address - Street 1:88 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5407
Mailing Address - Country:US
Mailing Address - Phone:207-945-5581
Mailing Address - Fax:
Practice Address - Street 1:88 MAPLE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5407
Practice Address - Country:US
Practice Address - Phone:207-945-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1576235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist