Provider Demographics
NPI:1124696026
Name:JOHNSON, ALICIA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
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 1:30138 DISNEY LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-1230
Mailing Address - Country:US
Mailing Address - Phone:916-717-7658
Mailing Address - Fax:
Practice Address - Street 1:411 W HAYCRAFT AVE STE D1
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8104
Practice Address - Country:US
Practice Address - Phone:208-664-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-4645235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist