MEDICARE: MR. CLARENCE 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	S0851	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710152178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLARENCE JOHNSON CCC-SLP

Provider Business Mailing Address
First Line	:	1129 MORGAN ST.
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732
Country	:	US
Telephone Number	:	662-398-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	1129 MORGAN ST.
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732
Country	:	US
Telephone Number	:	662-398-7575
Fax Number	:

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

Provider Enumeration Date	:	04/28/2008
Last Update Date	:	04/28/2008

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