Basic Information
| Provider Information | |||||||||
| NPI: | 1245951623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.S CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2547 LENWOOD LN NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495253905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162729255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166855000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2022 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 14404401 | MI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.