Provider Demographics
NPI:1285153395
Name:JOHNSON, CARLY (AUD)
Entity type:Individual
Prefix:DR
First Name:CARLY
Middle Name:
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 1:31 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2363
Mailing Address - Country:US
Mailing Address - Phone:203-234-1324
Mailing Address - Fax:855-476-0993
Practice Address - Street 1:46 PRINCE ST STE 601
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1634
Practice Address - Country:US
Practice Address - Phone:203-752-1726
Practice Address - Fax:855-451-0554
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000672231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000672OtherCT LICENSE
CT15400058OtherCAQH