Basic Information
Provider Information | |||||||||
NPI: | 1609152206 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | TUNISIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8800 SE SUNNYSIDE RD | ||||||||
Address2: | STE. 300-N | ||||||||
City: | CLACKAMAS | ||||||||
State: | OR | ||||||||
PostalCode: | 970155738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036595115 | ||||||||
FaxNumber: | 5036595968 | ||||||||
Practice Location | |||||||||
Address1: | 133 ROLLINS AVE | ||||||||
Address2: | UNIT 2 | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208524040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3014687670 | ||||||||
FaxNumber: | 3014687620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2011 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 01242 | MD | N |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   | 237600000X | AUD000124 | DC | N |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   | 231H00000X | AUD000124 | DC | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.