=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174166839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAKEYA JOYCE JOHNSON LCMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2019
-----------------------------------------------------
Last Update Date | 10/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 S MICHIGAN AVE STE 2020
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60603-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-732-0616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3745 216TH PL
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-2722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-288-5422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 227.021385
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------