Healthcare Provider Details

I. General information

NPI: 1487984266
Provider Name (Legal Business Name): CANDI JOHNSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E HANCOCK ST
NEWBERG OR
97132-2824
US

IV. Provider business mailing address

PO BOX 474
NEWBERG OR
97132-0474
US

V. Phone/Fax

Practice location:
  • Phone: 503-538-1114
  • Fax:
Mailing address:
  • Phone: 503-538-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1752
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: