Basic Information
| Provider Information | |||||||||
| NPI: | 1285153395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 31 BROADWAY FL 2 | ||||||||
| Address2: | |||||||||
| City: | NORTH HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064732363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032341324 | ||||||||
| FaxNumber: | 8554760993 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 PRINCE ST STE 601 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037521726 | ||||||||
| FaxNumber: | 8554510554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2017 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 000672 | CT | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 000672 | 01 | CT | CT LICENSE | OTHER | 15400058 | 01 | CT | CAQH | OTHER |