Provider Demographics
NPI:1366617649
Name:JOHANSEN, ANNA LEE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:LEE
Last Name:JOHANSEN
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 1:47760 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:BECIDA
Mailing Address - State:MN
Mailing Address - Zip Code:56678-4493
Mailing Address - Country:US
Mailing Address - Phone:218-854-7334
Mailing Address - Fax:
Practice Address - Street 1:47760 SUNSET DR
Practice Address - Street 2:
Practice Address - City:BECIDA
Practice Address - State:MN
Practice Address - Zip Code:56678-4493
Practice Address - Country:US
Practice Address - Phone:218-854-7334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN250269235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist