Healthcare Provider Details

I. General information

NPI: 1154673036
Provider Name (Legal Business Name): ELISABETH COURTENAY JOHNSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 SOUTH 17TH STREET
TACOMA WA
98405
US

IV. Provider business mailing address

P.O. BOX 1357
TACOMA WA
98401-1357
US

V. Phone/Fax

Practice location:
  • Phone: 253-571-4500
  • Fax:
Mailing address:
  • Phone: 253-571-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 00007717
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: