Provider Demographics
NPI:1841546850
Name:JOHNSON, MARIE A (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:A
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-4355
Mailing Address - Fax:423-439-4607
Practice Address - Street 1:156 S DOSSETT DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-1702
Practice Address - Country:US
Practice Address - Phone:423-439-4355
Practice Address - Fax:423-439-4607
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP0000004374235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12146389OtherASHA
TN1511884Medicaid
TNSP0000004374OtherST LICENSE
TN12146389OtherASHA