Provider Demographics
NPI:1518395326
Name:JOHNSON, LORA BROOKE (ATC, CLT, MS)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:BROOKE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC, CLT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GREEN MOUNTAIN DR UNIT 306
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7965
Mailing Address - Country:US
Mailing Address - Phone:802-249-2909
Mailing Address - Fax:
Practice Address - Street 1:27 GREEN MOUNTAIN DR UNIT 306
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7965
Practice Address - Country:US
Practice Address - Phone:802-249-2909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
VT0803022362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No133N00000XDietary & Nutritional Service ProvidersNutritionist