Provider Demographics
NPI:1821018987
Name:JOHNSON, MICHAEL L (LMT, LAT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SCIENCE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1074
Mailing Address - Country:US
Mailing Address - Phone:608-265-8349
Mailing Address - Fax:
Practice Address - Street 1:621 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1074
Practice Address - Country:US
Practice Address - Phone:608-265-8349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50-0392255A2300X
WI1853-046246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1853-046OtherCERT MASSAGE THERAPIST
WI50-039OtherATHLETIC TRAINER