Provider Demographics
NPI:1992960306
Name:JOHNSON, TRACIE LYNN (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:LYNN
Last Name:JOHNSON
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 1:6304 KOOSA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MS
Mailing Address - Zip Code:39342-9458
Mailing Address - Country:US
Mailing Address - Phone:205-317-7757
Mailing Address - Fax:
Practice Address - Street 1:6304 KOOSA DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MS
Practice Address - Zip Code:39342-9458
Practice Address - Country:US
Practice Address - Phone:205-317-7757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist