Provider Demographics
NPI:1215168620
Name:JOHNSON, SUSAN R (MS CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 NW HARRIMAN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2789
Mailing Address - Country:US
Mailing Address - Phone:541-420-5934
Mailing Address - Fax:
Practice Address - Street 1:760 NW HARRIMAN ST STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2789
Practice Address - Country:US
Practice Address - Phone:541-420-5934
Practice Address - Fax:541-383-2152
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12019235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist