Healthcare Provider Details

I. General information

NPI: 1295091080
Provider Name (Legal Business Name): REBECA C JOHNSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 NE 4TH PLAIN SUITE B
VANCOUVER WA
98664
US

IV. Provider business mailing address

11015 NE 4TH PLAIN SUITE B
VANCOUVER WA
98664
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-0451
  • Fax: 360-892-1601
Mailing address:
  • Phone: 360-892-0451
  • Fax: 360-892-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60249677
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: