Healthcare Provider Details

I. General information

NPI: 1851980072
Provider Name (Legal Business Name): ELLEN JOHNSON M.S. , CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 INTERSTATE DR
WENTZVILLE MO
63385-4725
US

IV. Provider business mailing address

2000 INTERSTATE DR
WENTZVILLE MO
63385-4725
US

V. Phone/Fax

Practice location:
  • Phone: 636-445-5190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2024027124
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-129406
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: