Provider Demographics
NPI:1619334547
Name:JOHNSON, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
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:PO BOX 821643
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-0038
Mailing Address - Country:US
Mailing Address - Phone:360-936-8785
Mailing Address - Fax:
Practice Address - Street 1:13115 NE 4TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5957
Practice Address - Country:US
Practice Address - Phone:360-696-1070
Practice Address - Fax:360-737-0200
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR03262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist