Provider Demographics
NPI:1063599512
Name:JOHNS, KENNETH HERBERT (MAUD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:HERBERT
Last Name:JOHNS
Suffix:
Gender:M
Credentials:MAUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WELLNESS BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2871
Mailing Address - Country:US
Mailing Address - Phone:803-765-1919
Mailing Address - Fax:803-749-3371
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 130
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6849
Practice Address - Country:US
Practice Address - Phone:803-765-1919
Practice Address - Fax:803-771-9084
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1067231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0061Medicaid