Provider Demographics
NPI:1265655492
Name:JOHNSON, TYREE CONNOR (LMP)
Entity Type:Individual
Prefix:MR
First Name:TYREE
Middle Name:CONNOR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4902
Mailing Address - Country:US
Mailing Address - Phone:360-319-1599
Mailing Address - Fax:
Practice Address - Street 1:1470 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4904
Practice Address - Country:US
Practice Address - Phone:360-734-9555
Practice Address - Fax:360-734-9556
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018088225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist