Provider Demographics
NPI:1144532599
Name:JOHNSON, GREGORY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
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 1:1705 HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5715
Mailing Address - Country:US
Mailing Address - Phone:224-715-5561
Mailing Address - Fax:
Practice Address - Street 1:1705 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5715
Practice Address - Country:US
Practice Address - Phone:224-715-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242001585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist