Provider Demographics
NPI:1497291918
Name:JOHNSON, KATIE LANE (MS CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KATIE
Middle Name:LANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:KATIE
Other - Middle Name:JOHNSON
Other - Last Name:BROYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:230 ROPER MOUNTAIN ROAD EXT APT 925J
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6919
Mailing Address - Country:US
Mailing Address - Phone:540-797-2544
Mailing Address - Fax:
Practice Address - Street 1:500 DOWNS LOOP
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2035
Practice Address - Country:US
Practice Address - Phone:864-654-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007043235Z00000X
SC6179235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist