Provider Demographics
NPI:1528540788
Name:JOHNSON, BAILEY MACKENZIE
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:MACKENZIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 FURNEAUX LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-3514
Mailing Address - Country:US
Mailing Address - Phone:214-803-8857
Mailing Address - Fax:
Practice Address - Street 1:3109 FURNEAUX LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-3514
Practice Address - Country:US
Practice Address - Phone:214-803-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20000386182255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer