MEDICARE: CAMILLE JOHNSON MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP009511	GA

General Provider Information

NPI Number	:	1063957975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE JOHNSON MS CCC-SLP

Provider Business Mailing Address
First Line	:	2959 LEGACY PARK DR
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-4344
Country	:	US
Telephone Number	:	803-413-0489
Fax Number	:

Provider Business Practice Location Address
First Line	:	2959 LEGACY PARK DR
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-4344
Country	:	US
Telephone Number	:	803-413-0489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/31/2016
Last Update Date	:	02/09/2023

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