Provider Demographics
NPI:1689058612
Name:JOHNSON, SARA (LMT)
Entity Type:Individual
Prefix:
First Name:SARA
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 1:230 NEWPORT CENTER DR
Mailing Address - Street 2:#250
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7509
Mailing Address - Country:US
Mailing Address - Phone:612-716-8631
Mailing Address - Fax:
Practice Address - Street 1:230 NEWPORT CENTER DR
Practice Address - Street 2:#250
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7509
Practice Address - Country:US
Practice Address - Phone:612-716-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist