Healthcare Provider Details

I. General information

NPI: 1508269333
Provider Name (Legal Business Name): AMANDA FAY JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33234 WILLOW RD
NEW BOSTON MI
48164-9540
US

IV. Provider business mailing address

33234 WILLOW RD
NEW BOSTON MI
48164-9540
US

V. Phone/Fax

Practice location:
  • Phone: 734-778-4808
  • Fax:
Mailing address:
  • Phone: 734-778-4808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberL475986
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: