Provider Demographics
NPI:1376564781
Name:JOHANSON, MARCIA (PT)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:JOHANSON
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 1:588N SUNRISE AVE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2843
Mailing Address - Country:US
Mailing Address - Phone:916-782-7848
Mailing Address - Fax:916-782-7855
Practice Address - Street 1:11960 HERITAGE OAK PL STE 19
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2403
Practice Address - Country:US
Practice Address - Phone:530-878-5301
Practice Address - Fax:530-878-5303
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist