Healthcare Provider Details

I. General information

NPI: 1245951623
Provider Name (Legal Business Name): ALEXANDER S JOHNSON M.S CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

2547 LENWOOD LN NE
GRAND RAPIDS MI
49525-3905
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5000
  • Fax:
Mailing address:
  • Phone: 616-272-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14404401
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: