Provider Demographics
NPI:1558566588
Name:JOHNSON, KEVIN CHARLES (MS)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2731 WETMORE AVE
Mailing Address - Street 2:SUITE 208B
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3571
Mailing Address - Country:US
Mailing Address - Phone:425-303-9309
Mailing Address - Fax:425-303-9612
Practice Address - Street 1:8620 HOLLY DR
Practice Address - Street 2:SUITE 230
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-1825
Practice Address - Country:US
Practice Address - Phone:425-348-4505
Practice Address - Fax:425-348-4538
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL1063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist