Healthcare Provider Details

I. General information

NPI: 1912124199
Provider Name (Legal Business Name): TAMMY L JOHNSON CDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 ELOCHOMAN VALLEY RD
CATHLAMET WA
98612-9602
US

IV. Provider business mailing address

42 ELOCHOMAN VALLEY RD
CATHLAMET WA
98612-9602
US

V. Phone/Fax

Practice location:
  • Phone: 360-795-8630
  • Fax: 369-795-6224
Mailing address:
  • Phone: 360-795-8630
  • Fax: 369-795-6224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRD00048644
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: