Provider Demographics
NPI:1942034236
Name:JOHNSON, MICHELLE ANNETTE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNETTE
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 1:155 PANTHER WAY
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-3165
Mailing Address - Country:US
Mailing Address - Phone:719-685-2460
Mailing Address - Fax:
Practice Address - Street 1:155 PANTHER WAY
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-3165
Practice Address - Country:US
Practice Address - Phone:719-685-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO270870235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist