Healthcare Provider Details

I. General information

NPI: 1407077597
Provider Name (Legal Business Name): GRETCHEN T. JOHNSON PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SAINT MICHAELS DR SUITE A-201
SANTA FE NM
87505-7672
US

IV. Provider business mailing address

1914 SAN ILDEFONSO RD
SANTA FE NM
87505-3344
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-5629
  • Fax:
Mailing address:
  • Phone: 505-983-5672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number902
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: