Provider Demographics
NPI:1063759173
Name:JOHNSON, HEATHER OGLE (MEDCCCSLP)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:OGLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MEDCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 MASON RD
Mailing Address - Street 2:
Mailing Address - City:ELORA
Mailing Address - State:TN
Mailing Address - Zip Code:37328-4227
Mailing Address - Country:US
Mailing Address - Phone:931-937-0961
Mailing Address - Fax:
Practice Address - Street 1:4081 THORNTON TAYLOR PKWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2674
Practice Address - Country:US
Practice Address - Phone:931-433-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSP 0000001845235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist