Provider Demographics
NPI:1215149604
Name:JOHANSEN, NANCY
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BALDWIN DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-1905
Mailing Address - Country:US
Mailing Address - Phone:207-947-0428
Mailing Address - Fax:
Practice Address - Street 1:1 CUMBERLAND PL
Practice Address - Street 2:SUITE 108
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5083
Practice Address - Country:US
Practice Address - Phone:207-990-9000
Practice Address - Fax:207-945-8645
Is Sole Proprietor?:No
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist