MEDICARE: LISA R. 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	008351-1	NY

General Provider Information

NPI Number	:	1255645818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA R. JOHNSON CCC-SLP

Provider Business Mailing Address
First Line	:	4563 RIDGE RD
Second Line	:
City	:	CANANDAIGUA
State	:	NY
Zip	:	14424-9600
Country	:	US
Telephone Number	:	585-259-5316
Fax Number	:	585-394-7547

Provider Business Practice Location Address
First Line	:	4563 RIDGE RD
Second Line	:
City	:	CANANDAIGUA
State	:	NY
Zip	:	14424-9600
Country	:	US
Telephone Number	:	585-259-5316
Fax Number	:	585-394-7547

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

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	08/05/2010

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