Basic Information
| Provider Information | |||||||||
| NPI: | 1780832212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 BEVERLY WAY | ||||||||
| Address2: | AEGIS THERAPIES | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778238375 | ||||||||
| FaxNumber: | 4792012703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1703 60TH ST | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626584125 | ||||||||
| FaxNumber: | 2626582196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 602154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 42725300 | 05 | WI | MEDICAID |