Provider Demographics
NPI:1093995151
Name:JOHNSON, CARRIE ANNE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W SOUTH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4053
Mailing Address - Country:US
Mailing Address - Phone:559-202-9637
Mailing Address - Fax:
Practice Address - Street 1:1102 W SOUTH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4053
Practice Address - Country:US
Practice Address - Phone:559-202-9637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist