Provider Demographics
NPI:1962944173
Name:JOHNSON, MARIEL DION (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:DION
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-4837
Mailing Address - Country:US
Mailing Address - Phone:646-894-1997
Mailing Address - Fax:
Practice Address - Street 1:12 HOLLY ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-4837
Practice Address - Country:US
Practice Address - Phone:551-225-0413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00760100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist