Provider Demographics
NPI:1164725727
Name:JOHNSON, KARLI
Entity Type:Individual
Prefix:
First Name:KARLI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 LIBERTY ST SE STE 170
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4149
Mailing Address - Country:US
Mailing Address - Phone:503-588-6633
Mailing Address - Fax:503-540-3427
Practice Address - Street 1:960 LIBERTY ST SE STE 170
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4149
Practice Address - Country:US
Practice Address - Phone:503-588-6633
Practice Address - Fax:503-540-3427
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17108225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist