Provider Demographics
NPI:1578896098
Name:JOHNSON, MICHELE M (LMT, NCTMB)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 S KNOWLES AVE
Mailing Address - Street 2:S 103
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-2529
Mailing Address - Country:US
Mailing Address - Phone:715-381-3829
Mailing Address - Fax:
Practice Address - Street 1:1477 S KNOWLES AVE
Practice Address - Street 2:S 103
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2529
Practice Address - Country:US
Practice Address - Phone:715-381-3829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0000048174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist