Basic Information
| Provider Information | |||||||||
| NPI: | 1972831923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258361034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22500 NE MARKETPLACE DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980532033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258361034 | ||||||||
| FaxNumber: | 4258361037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2009 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA60117438 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0257710 | 01 | WA | L&I | OTHER |