Provider Demographics
NPI:1720336621
Name:JOHNSON, MADISON (MED,CCC-SLP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:MCDUFFIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED,CCC-SLP
Mailing Address - Street 1:613 COOK ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-3933
Mailing Address - Country:US
Mailing Address - Phone:706-491-5409
Mailing Address - Fax:
Practice Address - Street 1:613 COOK ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-3933
Practice Address - Country:US
Practice Address - Phone:706-491-5409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008142235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003135730AMedicaid