MEDICARE: MRS. CARRIE ANNE JOHNSON MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 2935	AR

General Provider Information

NPI Number	:	1093995151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARRIE ANNE JOHNSON MPT

Provider Business Mailing Address
First Line	:	1102 W SOUTH ST
Second Line	:	SUITE 10
City	:	BENTON
State	:	AR
Zip	:	72015-4053
Country	:	US
Telephone Number	:	559-202-9637
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 W SOUTH ST
Second Line	:	SUITE 10
City	:	BENTON
State	:	AR
Zip	:	72015-4053
Country	:	US
Telephone Number	:	559-202-9637
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2007
Last Update Date	:	03/07/2013

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