MEDICARE: MRS. ASHLEY D JOHNSON 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	6678	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1397F	OTHER	NC	BLUE CROSS BLUE SHIELD NC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104804020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ASHLEY D JOHNSON CCC-SLP

Provider Business Mailing Address
First Line	:	153 DEEP RUN DRIVE
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28560-5206
Country	:	US
Telephone Number	:	252-638-3147
Fax Number	:	252-636-3170

Provider Business Practice Location Address
First Line	:	153 DEEP RUN DRIVE
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28560-5206
Country	:	US
Telephone Number	:	252-638-3147
Fax Number	:	252-636-3170

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	07/09/2007

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