Provider Demographics
NPI:1942690219
Name:JOHNSON, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
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 2332
Mailing Address - Street 2:
Mailing Address - City:SELLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85634-2332
Mailing Address - Country:US
Mailing Address - Phone:520-383-6800
Mailing Address - Fax:
Practice Address - Street 1:INDIAN ROUTE 19
Practice Address - Street 2:MILE POST 19.5
Practice Address - City:TOPAWA
Practice Address - State:AZ
Practice Address - Zip Code:85639
Practice Address - Country:US
Practice Address - Phone:520-383-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer