Provider Demographics
NPI:1609612167
Name:JOHNSON, ALISA (HIS)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 W JEFFERSON ST STE 206
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5264
Mailing Address - Country:US
Mailing Address - Phone:815-744-1214
Mailing Address - Fax:815-725-6507
Practice Address - Street 1:3077 W JEFFERSON ST STE 206
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5264
Practice Address - Country:US
Practice Address - Phone:815-744-1214
Practice Address - Fax:815-725-6507
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3316237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist