Provider Demographics
NPI:1629219613
Name:JOHNSON, LORITA ELAINE (LMT)
Entity Type:Individual
Prefix:
First Name:LORITA
Middle Name:ELAINE
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:PO BOX 1615
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-1615
Mailing Address - Country:US
Mailing Address - Phone:971-285-2905
Mailing Address - Fax:
Practice Address - Street 1:24850 SE STARK ST STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8320
Practice Address - Country:US
Practice Address - Phone:971-285-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6181172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist