Provider Demographics
NPI:1952350191
Name:JOHNSON, WYTONA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:WYTONA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 POWDER SPRINGS RD SW
Mailing Address - Street 2:SUITE 190, PMB 115
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4850
Mailing Address - Country:US
Mailing Address - Phone:770-438-6928
Mailing Address - Fax:770-438-6931
Practice Address - Street 1:620 POWDER SPRINGS ST SE
Practice Address - Street 2:SUITE E
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-3416
Practice Address - Country:US
Practice Address - Phone:770-438-6928
Practice Address - Fax:678-623-5387
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP002031235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000675474DMedicaid
GA7197816Medicare UPIN
GA52269071Medicare UPIN
GA000675474DMedicaid