=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184840936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE Q. JOHNSON PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 W YELM AVE
-----------------------------------------------------
City | YELM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98597-7679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-458-2444
-----------------------------------------------------
Fax | 360-458-2747
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4631 WHITMAN LN SE STE D
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98513-2250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-458-2444
-----------------------------------------------------
Fax | 360-458-2747
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT00009980
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------