Provider Demographics
NPI:1386948867
Name:IMBESI, JOHANNA W (SLP)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:W
Last Name:IMBESI
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1467
Mailing Address - Country:US
Mailing Address - Phone:301-989-5672
Mailing Address - Fax:
Practice Address - Street 1:13400 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1467
Practice Address - Country:US
Practice Address - Phone:301-989-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2020-11-21
Deactivation Date:2011-11-03
Deactivation Code:
Reactivation Date:2019-06-19
Provider Licenses
StateLicense IDTaxonomies
MD03525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist