Healthcare Provider Details

I. General information

NPI: 1154048908
Provider Name (Legal Business Name): BRANDY NICOLE JOHNSON CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 N OAK ST
VALDOSTA GA
31601-4579
US

IV. Provider business mailing address

300 SUNSET CIR
MOULTRIE GA
31768-6934
US

V. Phone/Fax

Practice location:
  • Phone: 229-241-7299
  • Fax: 229-241-7986
Mailing address:
  • Phone: 229-985-2080
  • Fax: 229-890-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP012363
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: