MEDICARE: LANDRIE MICHELE JOHANSEN PT, 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	1212126	TX

General Provider Information

NPI Number	:	1144507245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANDRIE MICHELE JOHANSEN PT, MPT

Provider Business Mailing Address
First Line	:	1100 BRIDGEWOOD DR STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0808
Country	:	US
Telephone Number	:	855-339-6378
Fax Number	:	855-329-6978

Provider Business Practice Location Address
First Line	:	1100 BRIDGEWOOD DR STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0808
Country	:	US
Telephone Number	:	855-339-6378
Fax Number	:	855-329-6978

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

Provider Enumeration Date	:	11/03/2011
Last Update Date	:	05/18/2024

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