Provider Demographics
NPI:1679291967
Name:JOHNSON, OLIVIA CAPISTRANO (CCC-SLP)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CAPISTRANO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8727 HONEYGO BLVD
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9687
Mailing Address - Country:US
Mailing Address - Phone:443-809-5065
Mailing Address - Fax:
Practice Address - Street 1:6901 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-3780
Practice Address - Country:US
Practice Address - Phone:443-809-4554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MD10737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist