Provider Demographics
NPI:1518294438
Name:JOHNSON, MICHELLE (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:REAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-5052
Mailing Address - Country:US
Mailing Address - Phone:918-756-3330
Mailing Address - Fax:918-756-3332
Practice Address - Street 1:114 W 7TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5052
Practice Address - Country:US
Practice Address - Phone:918-756-3330
Practice Address - Fax:918-756-3332
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4209225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200267380AMedicaid
OKOK404219Medicare PIN