Provider Demographics
NPI:1851374805
Name:JOHNSON, KATHLEEN SARAH (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:SARAH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2630
Mailing Address - Street 2:
Mailing Address - City:BORREGO SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92004-2630
Mailing Address - Country:US
Mailing Address - Phone:760-767-4047
Mailing Address - Fax:760-767-4048
Practice Address - Street 1:587 PALM CANYON DR STE. 204
Practice Address - Street 2:
Practice Address - City:BORREGO SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92004-2630
Practice Address - Country:US
Practice Address - Phone:760-767-4047
Practice Address - Fax:760-767-4048
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9855171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4006834Medicaid
CAPT9855Medicare ID - Type UnspecifiedCALIFORNIA LICENSE
CA4006834Medicaid