Provider Demographics
NPI:1033320262
Name:JOHNSON, SANDRA DANIELLE (LMP, NCTMB)
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:DANIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMP, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9757
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99209-9757
Mailing Address - Country:US
Mailing Address - Phone:509-325-6100
Mailing Address - Fax:509-326-1912
Practice Address - Street 1:621 W MALLON AVE
Practice Address - Street 2:300
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2163
Practice Address - Country:US
Practice Address - Phone:509-325-6100
Practice Address - Fax:509-326-1912
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015739225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA156794OtherL & I PROVIDER #