Provider Demographics
NPI:1720362213
Name:JOHNSON, KATY SUZANNE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KATY
Middle Name:SUZANNE
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 1:2114 MOHAWK RD APT B
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1227
Mailing Address - Country:US
Mailing Address - Phone:719-225-9908
Mailing Address - Fax:
Practice Address - Street 1:3606 MORRIS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1369
Practice Address - Country:US
Practice Address - Phone:719-225-9908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12505225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist