Provider Demographics
NPI:1730322264
Name:JOHNSON, ANGELA MARIE (MS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 GRAYSON RD
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3903
Mailing Address - Country:US
Mailing Address - Phone:618-841-1363
Mailing Address - Fax:
Practice Address - Street 1:611 S MARSHALL AVE # 429
Practice Address - Street 2:
Practice Address - City:MC LEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859-1213
Practice Address - Country:US
Practice Address - Phone:618-643-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist