Provider Demographics
NPI:1285215285
Name:JOHNSON, KERI LEE (LMT)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DEADWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57732-1004
Mailing Address - Country:US
Mailing Address - Phone:605-722-1396
Mailing Address - Fax:
Practice Address - Street 1:802 MAIN ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-1004
Practice Address - Country:US
Practice Address - Phone:605-722-1396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT10410225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist