Provider Demographics
NPI:1407077597
Name:JOHNSON, GRETCHEN T (PT, ATC)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 SAN ILDEFONSO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3344
Mailing Address - Country:US
Mailing Address - Phone:505-983-5672
Mailing Address - Fax:
Practice Address - Street 1:435 SAINT MICHAELS DR
Practice Address - Street 2:SUITE A-201
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7672
Practice Address - Country:US
Practice Address - Phone:505-982-5629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM902225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist