Healthcare Provider Details

I. General information

NPI: 1629219613
Provider Name (Legal Business Name): LORITA ELAINE JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

IV. Provider business mailing address

PO BOX 1615
SANDY OR
97055-1615
US

V. Phone/Fax

Practice location:
  • Phone: 971-285-2905
  • Fax:
Mailing address:
  • Phone: 971-285-2905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number6181
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: