Provider Demographics
NPI:1710911169
Name:JOHNSON, REBECCA LYNN (ATC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64505-2108
Mailing Address - Country:US
Mailing Address - Phone:816-383-3979
Mailing Address - Fax:
Practice Address - Street 1:802 N RIVERSIDE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-9794
Practice Address - Country:US
Practice Address - Phone:816-271-7676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040354172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer