Healthcare Provider Details

I. General information

NPI: 1902752207
Provider Name (Legal Business Name): KAILEY BREANNE JOHNSTON M.A. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42804 GARFIELD RD
CLINTON TOWNSHIP MI
48038-1656
US

IV. Provider business mailing address

12765 INDEPENDENCE AVE
SHELBY TOWNSHIP MI
48315-4641
US

V. Phone/Fax

Practice location:
  • Phone: 586-323-2957
  • Fax:
Mailing address:
  • Phone: 586-323-2957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14546363
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: