Healthcare Provider Details

I. General information

NPI: 1235193699
Provider Name (Legal Business Name): MARY CAROLINE JOHNSON M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VETERANS DR 126-CDD
LEXINGTON KY
40502-2235
US

IV. Provider business mailing address

3356 GRASMERE DR
LEXINGTON KY
40503-4020
US

V. Phone/Fax

Practice location:
  • Phone: 859-281-4972
  • Fax:
Mailing address:
  • Phone: 859-223-4805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0941
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: