Provider Demographics
NPI:1326640434
Name:JOHNSON, CYNTHIA DIANE (LICENSED MASSAGE TH)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICENSED MASSAGE TH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14184 COUNTY ROAD 1573
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1552
Mailing Address - Country:US
Mailing Address - Phone:580-399-3699
Mailing Address - Fax:
Practice Address - Street 1:119 N BROADWAY AVE STE 10
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5052
Practice Address - Country:US
Practice Address - Phone:580-399-3699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK184331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty