=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154048908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDY NICOLE JOHNSON CCC/SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2022
-----------------------------------------------------
Last Update Date | 10/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N OAK ST
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31601-4579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-241-7299
-----------------------------------------------------
Fax | 229-241-7986
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 SUNSET CIR
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31768-6934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-985-2080
-----------------------------------------------------
Fax | 229-890-3397
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP012363
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------