Provider Demographics
NPI:1104891043
Name:JOHNSON, ANITA L (AUD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-784-4251
Mailing Address - Fax:
Practice Address - Street 1:1 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-2000
Practice Address - Country:US
Practice Address - Phone:217-784-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00001206231H00000X
IL147001940231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAJO7114OtherINDIVIDUAL BLUE SHIELD
WAP09825OtherPIERCE COUNTY
WA8338782Medicaid
WA640004086OtherRAILROAD MEDICARE
WAAB23719Medicare PIN
WA8338782Medicaid