Healthcare Provider Details

I. General information

NPI: 1790137834
Provider Name (Legal Business Name): NICHOLE JOHNSON M.A., CCC/SLP-L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 LINCOLN ST
CENTERVILLE SD
57014-2040
US

IV. Provider business mailing address

30437 UNIVERSITY RD
CENTERVILLE SD
57014-6536
US

V. Phone/Fax

Practice location:
  • Phone: 605-563-2291
  • Fax:
Mailing address:
  • Phone: 605-563-2291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number015-SLP
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: