Provider Demographics
NPI:1619568995
Name:JOHNSON, OLIVIA (LMT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 E MCANDREWS RD STE D
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5576
Mailing Address - Country:US
Mailing Address - Phone:541-414-0362
Mailing Address - Fax:541-200-2262
Practice Address - Street 1:2921 DOCTORS PARK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8127
Practice Address - Country:US
Practice Address - Phone:541-414-0362
Practice Address - Fax:541-200-2262
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR25888OtherOREGON HEALTH DEPARTMENT