Provider Demographics
NPI:1891012779
Name:MARK, JOHANNA L (LMP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:L
Last Name:MARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4518 RIDGEWOOD CT NW
Mailing Address - Street 2:#8
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-3683
Mailing Address - Country:US
Mailing Address - Phone:206-251-8144
Mailing Address - Fax:
Practice Address - Street 1:313 5TH AVE SE
Practice Address - Street 2:SUITE B
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1191
Practice Address - Country:US
Practice Address - Phone:360-357-6953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA6005893225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist