Provider Demographics
NPI:1760530125
Name:JOHNSON, MARYDAYLYN MALAQUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARYDAYLYN
Middle Name:MALAQUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MARYDAYLYN
Other - Middle Name:MALAQUE
Other - Last Name:MAGHUZOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3623 SE WILDFLOWER PL
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123
Mailing Address - Country:US
Mailing Address - Phone:503-649-7901
Mailing Address - Fax:503-649-7901
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:CONSONUS REHAB SERVICES 100
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-5129
Practice Address - Fax:971-206-5209
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5029225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist