Healthcare Provider Details

I. General information

NPI: 1841556180
Provider Name (Legal Business Name): MINDY JOHNSON M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8168 LONE BOULDER ST
LAS VEGAS NV
89113-4659
US

IV. Provider business mailing address

9056 RUSTY RIFLE AVE
LAS VEGAS NV
89143-1165
US

V. Phone/Fax

Practice location:
  • Phone: 702-236-2266
  • Fax: 702-476-9991
Mailing address:
  • Phone: 702-236-2266
  • Fax: 702-476-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-1251
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: