Healthcare Provider Details

I. General information

NPI: 1407339419
Provider Name (Legal Business Name): SAMANTHA JO JOHNSON BS, SLP-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W SEMANDS ST
CONROE TX
77301-1867
US

IV. Provider business mailing address

21899 VALLEY RANCH CROSSING DR APT 334
PORTER TX
77365-7307
US

V. Phone/Fax

Practice location:
  • Phone: 936-756-5598
  • Fax: 936-249-2244
Mailing address:
  • Phone: 936-615-5985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number40554
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: