Provider Demographics
NPI:1104964188
Name:JOHNSON, BRIAN R (SP)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 NE 10TH ST
Mailing Address - Street 2:BELLEVUE MEDICAL CENTER
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8578
Mailing Address - Country:US
Mailing Address - Phone:425-502-3898
Mailing Address - Fax:425-502-4233
Practice Address - Street 1:626 120TH AVE NE
Practice Address - Street 2:SUITE B201
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3077
Practice Address - Country:US
Practice Address - Phone:425-556-6330
Practice Address - Fax:425-556-6325
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003248235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8410839Medicaid