MEDICARE: KIMBERLY ANNE 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	TSLP-4434	ID
2	235Z00000X	Speech-Language Pathologist		ID
3	235Z00000X	Speech-Language Pathologist	18242	OR

General Provider Information

NPI Number	:	1114531480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ANNE JOHNSON MS, CCC-SLP

Provider Business Mailing Address
First Line	:	593 NW YORK DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-7264
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	593 NW YORK DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-7264
Country	:	US
Telephone Number	:	971-346-0355
Fax Number	:

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

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/05/2024

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Directions to “ KIMBERLY ANNE JOHNSON MS, CCC-SLP” Practice Location

Language	Start Address	Practice Location

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