Provider Demographics
NPI:1801147822
Name:JOHNSON, AMANDA JOY
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JOY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 W 64TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1001
Mailing Address - Country:US
Mailing Address - Phone:612-798-8345
Mailing Address - Fax:
Practice Address - Street 1:2400 W 64TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55423-1001
Practice Address - Country:US
Practice Address - Phone:612-708-8345
Practice Address - Fax:612-861-6050
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist