Provider Demographics
NPI:1942406723
Name:WALLACE, JOHANNA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13727 WAVERLY CREST CT STE 200
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-6831
Mailing Address - Country:US
Mailing Address - Phone:850-512-0156
Mailing Address - Fax:
Practice Address - Street 1:11440 MATZKE RD
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5015
Practice Address - Country:US
Practice Address - Phone:850-512-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2024-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist