Provider Demographics
NPI:1407547086
Name:JOHNSON, TY EVERETTE
Entity Type:Individual
Prefix:
First Name:TY
Middle Name:EVERETTE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 E L ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-3124
Mailing Address - Country:US
Mailing Address - Phone:307-575-2445
Mailing Address - Fax:
Practice Address - Street 1:2802 W C ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-1834
Practice Address - Country:US
Practice Address - Phone:307-532-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator