Provider Demographics
NPI:1154048908
Name:JOHNSON, BRANDY NICOLE (CCC/SLP)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6934
Mailing Address - Country:US
Mailing Address - Phone:229-985-2080
Mailing Address - Fax:229-890-3397
Practice Address - Street 1:700 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-4579
Practice Address - Country:US
Practice Address - Phone:229-241-7299
Practice Address - Fax:229-241-7986
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist