Provider Demographics
NPI:1861999146
Name:JOHNSON, BIANCA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 BARNSWALLOW LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6229
Mailing Address - Country:US
Mailing Address - Phone:571-737-5713
Mailing Address - Fax:
Practice Address - Street 1:610 GAYLE ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-1324
Practice Address - Country:US
Practice Address - Phone:540-368-2559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist