Healthcare Provider Details

I. General information

NPI: 1467500272
Provider Name (Legal Business Name): CYNTHIA EVANS JOHNSON L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 EASTWAY DR
ISLAND LAKE IL
60042-9448
US

IV. Provider business mailing address

3311 EASTWAY DR
ISLAND LAKE IL
60042-9448
US

V. Phone/Fax

Practice location:
  • Phone: 847-487-7448
  • Fax:
Mailing address:
  • Phone: 847-487-7448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.002888
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: