Provider Demographics
NPI:1306829312
Name:JOHNSON, MARILYNNE (PT)
Entity Type:Individual
Prefix:
First Name:MARILYNNE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
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 805
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-0805
Mailing Address - Country:US
Mailing Address - Phone:802-878-9513
Mailing Address - Fax:802-878-9962
Practice Address - Street 1:67 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:ESSEX JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05452-3235
Practice Address - Country:US
Practice Address - Phone:802-878-9513
Practice Address - Fax:802-878-9513
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0001066225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002684Medicaid
VT0002684Medicaid