Provider Demographics
NPI:1407085319
Name:JOHANSEN, DOROTHEA DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:DOROTHEA
Middle Name:DAVID
Last Name:JOHANSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 ENGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1114
Mailing Address - Country:US
Mailing Address - Phone:651-647-1733
Mailing Address - Fax:
Practice Address - Street 1:366 PRIOR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5165
Practice Address - Country:US
Practice Address - Phone:651-647-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor