MEDICARE: MICHAEL GABRIEL JOHNSON

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	225700000X	Massage Therapist	MT104482	TX
2	225700000X	Massage Therapist	MT107482	TX

General Provider Information

NPI Number	:	1790288447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL GABRIEL JOHNSON

Provider Business Mailing Address
First Line	:	8316 TRACE RIDGE PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-5913
Country	:	US
Telephone Number	:	817-353-4961
Fax Number	:

Provider Business Practice Location Address
First Line	:	7405 BUTTONWOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1308
Country	:	US
Telephone Number	:	817-353-4961
Fax Number	:

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

Provider Enumeration Date	:	03/08/2018
Last Update Date	:	03/08/2018

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